- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.85 / $344.85 / $731.93
| Facility | | $344.85 | $344.85 | $731.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.43 / $336.43 / $370.08
| Professional | | $336.43 | $336.43 | $370.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.60 / $217.08 / $218.70
| Professional | | $183.60 | $217.08 | $218.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.50 / $170.19 / $214.00
| Professional | | $168.50 | $170.19 | $214.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.85 / $344.85 / $586.25
| Facility | | $344.85 | $344.85 | $586.25 |