- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $299.14 / $367.94 / $367.94
| Facility | | $299.14 | $367.94 | $367.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.46 / $299.14 / $367.94
| Professional | | $239.46 | $299.14 | $367.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.48 / $302.60 / $423.24
| Professional | | $248.48 | $302.60 | $423.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.77 / $281.77 / $281.77
| Professional | | $281.77 | $281.77 | $281.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.66 / $386.34 / $840.58
| Facility | | $267.66 | $386.34 | $840.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.62 / $1,905.62 / $1,905.62
| Professional | | $1,905.62 | $1,905.62 | $1,905.62 |