- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.58 / $389.58 / $389.58
| Professional | | $389.58 | $389.58 | $389.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.68 / $252.68 / $252.68
| Facility | | $252.68 | $252.68 | $252.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.10 / $252.68 / $260.26
| Professional | | $194.10 | $252.68 | $260.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.22 / $130.22 / $130.22
| Facility | | $130.22 | $130.22 | $130.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.15 / $384.15 / $384.15
| Professional | | $384.15 | $384.15 | $384.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.22 / $130.22 / $252.68
| Facility | | $130.22 | $130.22 | $252.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.10 / $260.26 / $473.87
| Professional | | $194.10 | $260.26 | $473.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.58 / $268.98 / $515.54
| Professional | | $260.58 | $268.98 | $515.54 |