- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $316.23
| Facility | | $316.23 | $316.23 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $316.23 / $478.63
| Professional | | $251.19 | $316.23 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $776.25
| Professional | | $616.60 | $616.60 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $316.23
| Facility | | $316.23 | $316.23 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $316.23 / $602.56
| Professional | | $251.19 | $316.23 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $229.09 / $676.08
| Facility | | $190.55 | $229.09 | $676.08 |