- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.77 / $437.77 / $437.77
| Facility | | $437.77 | $437.77 | $437.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.37 / $437.77 / $437.77
| Professional | | $352.37 | $437.77 | $437.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.99 / $464.34 / $570.21
| Professional | | $285.99 | $464.34 | $570.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.80 / $570.21 / $570.21
| Professional | | $189.80 | $570.21 | $570.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.34 / $558.79 / $1,030.08
| Professional | | $354.34 | $558.79 | $1,030.08 |