- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $407.38 / $660.69
| Facility | | $354.81 | $407.38 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $245.47 / $316.23
| Professional | | $204.17 | $245.47 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Professional | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $426.58 / $426.58
| Facility | | $302.00 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $524.81 / $524.81
| Professional | | $302.00 | $524.81 | $524.81 |