- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.71 / $242.71 / $242.71
| Facility | | $242.71 | $242.71 | $242.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.71 / $242.71 / $292.31
| Professional | | $242.71 | $242.71 | $292.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.04 / $116.04 / $275.86
| Professional | | $116.04 | $116.04 | $275.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.08 / $491.96 / $798.03
| Facility | | $302.08 | $491.96 | $798.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.86 / $275.86 / $275.86
| Facility | | $275.86 | $275.86 | $275.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.49 / $275.86 / $283.43
| Professional | | $250.49 | $275.86 | $283.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $557.32 / $557.32 / $557.32
| Professional | | $557.32 | $557.32 | $557.32 |