- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.81 / $483.81 / $887.99
| Facility | | $483.81 | $483.81 | $887.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.80 / $483.81 / $922.50
| Professional | | $310.80 | $483.81 | $922.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.44 / $1,056.36 / $1,064.25
| Professional | | $893.44 | $1,056.36 | $1,064.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.55 / $228.18 / $231.83
| Professional | | $182.55 | $228.18 | $231.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.81 / $483.81 / $822.48
| Facility | | $483.81 | $483.81 | $822.48 |