- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $467.74
| Facility | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $467.74
| Professional | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $1,202.26 / $1,548.82
| Facility | | $446.68 | $1,202.26 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $2,570.40
| Facility | | $1,071.52 | $1,202.26 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $398.11 / $562.34
| Facility | | $295.12 | $398.11 | $562.34 |