- 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 / $1,040.33
| Professional | | $248.71 | $248.71 | $1,040.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.20 / $311.44 / $653.74
| Facility | | $248.20 | $311.44 | $653.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.68 / $421.68 / $421.68
| Professional | | $421.68 | $421.68 | $421.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.71 / $248.71 / $1,040.33
| Facility | | $248.71 | $248.71 | $1,040.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $449.39 / $449.39 / $449.39
| Professional | | $449.39 | $449.39 | $449.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.62 / $197.62 / $291.62
| Professional | | $197.62 | $197.62 | $291.62 |