- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.89 / $250.89 / $250.89
| Facility | | $250.89 | $250.89 | $250.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.30 / $188.34 / $250.89
| Professional | | $183.30 | $188.34 | $250.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.49 / $412.49 / $412.49
| Professional | | $412.49 | $412.49 | $412.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.34 / $246.88 / $481.94
| Facility | | $188.34 | $246.88 | $481.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.36 / $1,066.36 / $1,066.36
| Professional | | $1,066.36 | $1,066.36 | $1,066.36 |