- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.51 / $329.51 / $329.51
| Facility | | $329.51 | $329.51 | $329.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.56 / $329.51 / $329.51
| Professional | | $325.56 | $329.51 | $329.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.89 / $511.00 / $1,054.00
| Professional | | $411.89 | $511.00 | $1,054.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $658.78 / $658.78 / $658.78
| Facility | | $658.78 | $658.78 | $658.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.59 / $535.79 / $732.47
| Professional | | $160.59 | $535.79 | $732.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.38 / $138.38 / $329.51
| Professional | | $138.38 | $138.38 | $329.51 |