- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $281.84 / $281.84
| Facility | | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $239.88 / $457.09
| Professional | | $194.98 | $239.88 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $436.52 / $891.25
| Professional | | $346.74 | $436.52 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $602.56
| Professional | | $457.09 | $457.09 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $281.84 / $281.84
| Facility | | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $117.49 / $281.84
| Professional | | $117.49 | $117.49 | $281.84 |