- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.15 / $338.48 / $501.74
| Facility | | $230.15 | $338.48 | $501.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $278.62
| Professional | | $230.15 | $230.15 | $278.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.55 / $255.55 / $255.55
| Professional | | $255.55 | $255.55 | $255.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $230.15
| Facility | | $230.15 | $230.15 | $230.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $230.15
| Professional | | $230.15 | $230.15 | $230.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $296.42 / $1,114.20 / $1,150.75
| Facility | | $296.42 | $1,114.20 | $1,150.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.81 / $230.15 / $230.15
| Professional | | $227.81 | $230.15 | $230.15 |