- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.47 / $307.47 / $744.07
| Facility | | $307.47 | $307.47 | $744.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.47 / $307.47 / $307.47
| Professional | | $307.47 | $307.47 | $307.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.04 / $457.04 / $513.54
| Professional | | $457.04 | $457.04 | $513.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.63 / $356.63 / $356.63
| Professional | | $356.63 | $356.63 | $356.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.31 / $488.31 / $1,491.27
| Professional | | $488.31 | $488.31 | $1,491.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.86 / $374.79 / $563.12
| Professional | | $249.86 | $374.79 | $563.12 |