- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.45 / $307.45 / $307.45
| Facility | | $307.45 | $307.45 | $307.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.50 / $307.45 / $307.45
| Professional | | $280.50 | $307.45 | $307.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $379.98 / $379.98 / $551.51
| Professional | | $379.98 | $379.98 | $551.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,365.68 / $3,106.85 / $3,109.25
| Facility | | $1,365.68 | $3,106.85 | $3,109.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.07 / $277.27 / $1,579.62
| Professional | | $218.07 | $277.27 | $1,579.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.27 / $741.14 / $741.14
| Professional | | $329.27 | $741.14 | $741.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.86 / $380.83 / $1,108.67
| Professional | | $209.86 | $380.83 | $1,108.67 |