- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $239.88 / $239.88
| Facility | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $239.88 / $316.23
| Professional | | $229.09 | $239.88 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,949.84 / $3,801.89
| Facility | | $1,479.11 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $354.81 / $467.74
| Facility | | $239.88 | $354.81 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Professional | | $2,691.53 | $2,691.53 | $2,691.53 |