- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.36 / $253.36 / $968.73
| Facility | | $253.36 | $253.36 | $968.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.46 / $253.36 / $253.36
| Professional | | $238.46 | $253.36 | $253.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.36 / $263.29 / $278.20
| Facility | | $253.36 | $263.29 | $278.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.26 / $268.26 / $268.26
| Professional | | $268.26 | $268.26 | $268.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.36 / $253.36 / $253.36
| Facility | | $253.36 | $253.36 | $253.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.36 / $253.36 / $253.36
| Professional | | $253.36 | $253.36 | $253.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.39 / $248.39 / $248.39
| Professional | | $248.39 | $248.39 | $248.39 |