- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $401.62 / $401.62 / $509.35
| Facility | | $401.62 | $401.62 | $509.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.39 / $401.62 / $401.62
| Professional | | $289.39 | $401.62 | $401.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.22 / $192.15 / $471.70
| Facility | | $132.22 | $192.15 | $471.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.01 / $350.02 / $624.29
| Professional | | $280.01 | $350.02 | $624.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $474.40 / $474.40 / $474.40
| Facility | | $474.40 | $474.40 | $474.40 |