- 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
- $281.84 / $316.23 / $426.58
| Professional | | $281.84 | $316.23 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $251.19 / $251.19
| Professional | | $151.36 | $251.19 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $512.86 / $794.33
| Facility | | $245.47 | $512.86 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $549.54 / $741.31
| Facility | | $316.23 | $549.54 | $741.31 |