- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.58 / $359.68 / $781.83
| Facility | | $260.58 | $359.68 | $781.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.55 / $335.55 / $335.55
| Professional | | $335.55 | $335.55 | $335.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.63 / $313.63 / $335.55
| Professional | | $313.63 | $313.63 | $335.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.58 / $368.58 / $368.58
| Facility | | $368.58 | $368.58 | $368.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.80 / $394.76 / $473.71
| Professional | | $325.80 | $394.76 | $473.71 |