- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.71 / $248.71 / $248.71
| Facility | | $248.71 | $248.71 | $248.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.71 / $248.71 / $287.08
| Professional | | $248.71 | $248.71 | $287.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $337.64 / $584.36 / $952.82
| Facility | | $337.64 | $584.36 | $952.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $404.08 / $404.08 / $404.08
| Facility | | $404.08 | $404.08 | $404.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.56 / $324.56 / $324.56
| Professional | | $324.56 | $324.56 | $324.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.62 / $197.62 / $197.62
| Professional | | $197.62 | $197.62 | $197.62 |