- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $335.40 / $412.55 / $412.55
| Facility | | $335.40 | $412.55 | $412.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.20 / $339.35 / $412.55
| Professional | | $306.20 | $339.35 | $412.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.55 / $533.32 / $731.81
| Professional | | $399.55 | $533.32 | $731.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.89 / $534.89 / $534.89
| Professional | | $534.89 | $534.89 | $534.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $335.40 / $445.87 / $858.10
| Facility | | $335.40 | $445.87 | $858.10 |
- 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 |