- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.48 / $329.48 / $329.48
| Facility | | $329.48 | $329.48 | $329.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.16 / $329.48 / $550.91
| Professional | | $270.16 | $329.48 | $550.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.50 / $384.50 / $511.39
| Professional | | $384.50 | $384.50 | $511.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.02 / $356.09 / $1,488.94
| Professional | | $280.02 | $356.09 | $1,488.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.00 / $378.82 / $784.38
| Professional | | $322.00 | $378.82 | $784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.69 / $262.12 / $839.84
| Professional | | $220.69 | $262.12 | $839.84 |