- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.40 / $391.40 / $785.43
| Facility | | $391.40 | $391.40 | $785.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.39 / $391.40 / $756.50
| Professional | | $289.39 | $391.40 | $756.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.00 / $683.40 / $688.50
| Professional | | $578.00 | $683.40 | $688.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.01 / $282.81 / $355.62
| Professional | | $280.01 | $282.81 | $355.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.40 / $391.40 / $665.38
| Facility | | $391.40 | $391.40 | $665.38 |