- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $512.86
| Facility | | $416.87 | $416.87 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $630.96
| Professional | | $512.86 | $512.86 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.96 / $151.36 / $151.36
| Facility | | $10.96 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $151.36 / $158.49
| Professional | | $141.25 | $151.36 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $588.84
| Professional | | $512.86 | $512.86 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $281.84 / $549.54
| Facility | | $147.91 | $281.84 | $549.54 |