- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $497.46 / $497.46 / $497.46
| Facility | | $497.46 | $497.46 | $497.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.66 / $497.46 / $497.46
| Professional | | $252.66 | $497.46 | $497.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.46 / $440.46 / $440.46
| Professional | | $440.46 | $440.46 | $440.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.78 / $400.78 / $666.10
| Facility | | $400.78 | $400.78 | $666.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.57 / $400.78 / $583.27
| Professional | | $292.57 | $400.78 | $583.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.82 / $295.24 / $454.95
| Professional | | $196.82 | $295.24 | $454.95 |