- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.96 / $436.96 / $436.96
| Facility | | $436.96 | $436.96 | $436.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.45 / $335.40 / $436.96
| Professional | | $316.45 | $335.40 | $436.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.95 / $955.95 / $955.95
| Professional | | $955.95 | $955.95 | $955.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $333.56 / $434.27 / $657.98
| Facility | | $333.56 | $434.27 | $657.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,436.69 / $2,436.69 / $2,436.69
| Professional | | $2,436.69 | $2,436.69 | $2,436.69 |