- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $343.70 / $343.70 / $343.70
| Facility | | $343.70 | $343.70 | $343.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.36 / $263.80 / $343.70
| Professional | | $262.36 | $263.80 | $343.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $591.72 / $591.72 / $591.72
| Professional | | $591.72 | $591.72 | $591.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.21 / $263.80 / $353.49
| Facility | | $239.21 | $263.80 | $353.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.46 / $1,733.46 / $1,733.46
| Professional | | $1,733.46 | $1,733.46 | $1,733.46 |