- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $443.30 / $443.30 / $443.30
| Facility | | $443.30 | $443.30 | $443.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.15 / $443.30 / $443.30
| Professional | | $225.15 | $443.30 | $443.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.26 / $448.26 / $448.26
| Professional | | $448.26 | $448.26 | $448.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.25 / $357.25 / $357.25
| Professional | | $357.25 | $357.25 | $357.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.53 / $329.53 / $527.36
| Facility | | $329.53 | $329.53 | $527.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.56 / $329.53 / $461.77
| Professional | | $240.56 | $329.53 | $461.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.40 / $263.08 / $405.42
| Professional | | $175.40 | $263.08 | $405.42 |