- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $575.44
| Facility | | $354.81 | $354.81 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $269.15 / $346.74
| Professional | | $194.98 | $269.15 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $213.80 / $239.88
| Professional | | $141.25 | $213.80 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $426.58
| Professional | | $354.81 | $354.81 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Facility | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $275.42 / $346.74
| Professional | | $194.98 | $275.42 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $354.81 / $537.03
| Professional | | $213.80 | $354.81 | $537.03 |