- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.68 / $865.18 / $1,165.83
| Facility | | $308.68 | $865.18 | $1,165.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $308.68
| Professional | | $308.68 | $308.68 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.80 / $449.13 / $759.44
| Professional | | $306.80 | $449.13 | $759.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.20 / $291.20 / $308.68
| Facility | | $291.20 | $291.20 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.38 / $262.38 / $308.68
| Professional | | $262.38 | $262.38 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.89 / $308.68 / $500.30
| Professional | | $280.89 | $308.68 | $500.30 |