- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $384.85 / $1,190.72 / $1,450.23
| Facility | | $384.85 | $1,190.72 | $1,450.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.85 / $384.85 / $384.85
| Professional | | $384.85 | $384.85 | $384.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.64 / $570.77 / $965.12
| Professional | | $381.64 | $570.77 | $965.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.06 / $363.06 / $384.85
| Facility | | $363.06 | $363.06 | $384.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.12 / $327.12 / $384.85
| Professional | | $327.12 | $327.12 | $384.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.00 / $428.42 / $566.51
| Professional | | $381.00 | $428.42 | $566.51 |