- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.86 / $457.86 / $467.23
| Facility | | $457.86 | $457.86 | $467.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.76 / $449.88 / $467.23
| Professional | | $397.76 | $449.88 | $467.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.44 / $560.84 / $935.19
| Professional | | $316.44 | $560.84 | $935.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.66 / $568.04 / $935.19
| Professional | | $475.66 | $568.04 | $935.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.38 / $607.08 / $1,707.57
| Professional | | $587.38 | $607.08 | $1,707.57 |