- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $939.48 / $939.48 / $939.48
| Facility | | $939.48 | $939.48 | $939.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $444.72 / $939.48 / $939.48
| Professional | | $444.72 | $939.48 | $939.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.30 / $775.30 / $775.30
| Professional | | $775.30 | $775.30 | $775.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $740.83 / $740.83 / $1,051.31
| Facility | | $740.83 | $740.83 | $1,051.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.80 / $740.83 / $920.56
| Professional | | $540.80 | $740.83 | $920.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.45 / $515.04 / $782.82
| Professional | | $346.45 | $515.04 | $782.82 |