- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $645.65 / $645.65
| Facility | | $501.19 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $501.19 / $758.58
| Professional | | $354.81 | $501.19 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $316.23 / $724.44
| Professional | | $295.12 | $316.23 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $50.12
| Professional | | $39.81 | $39.81 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | | $1,071.52 | $1,071.52 | $1,071.52 |