- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $628.42 / $628.42 / $628.42
| Facility | | $628.42 | $628.42 | $628.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.48 / $628.42 / $628.42
| Professional | | $297.48 | $628.42 | $628.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.61 / $518.61 / $518.61
| Professional | | $518.61 | $518.61 | $518.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.50 / $437.50 / $693.00
| Facility | | $437.50 | $437.50 | $693.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.38 / $437.50 / $606.82
| Professional | | $319.38 | $437.50 | $606.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.90 / $314.94 / $484.53
| Professional | | $205.90 | $314.94 | $484.53 |