- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.62 / $362.62 / $362.62
| Facility | | $362.62 | $362.62 | $362.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.11 / $90.11 / $128.72
| Professional | | $90.11 | $90.11 | $128.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.40 / $356.40 / $357.75
| Professional | | $356.40 | $356.40 | $357.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.40 / $347.40 / $362.62
| Facility | | $347.40 | $347.40 | $362.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.11 / $90.11 / $128.72
| Professional | | $90.11 | $90.11 | $128.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.86 / $319.29 / $1,218.03
| Professional | | $212.86 | $319.29 | $1,218.03 |