- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $656.21 / $656.21 / $984.32
| Facility | | $656.21 | $656.21 | $984.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.21 / $656.21 / $812.28
| Professional | | $656.21 | $656.21 | $812.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.06 / $162.06 / $162.06
| Facility | | $162.06 | $162.06 | $162.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.47 / $81.01 / $242.55
| Facility | | $37.47 | $81.01 | $242.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.54 / $519.54 / $649.44
| Professional | | $519.54 | $519.54 | $649.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.26 / $130.26 / $130.26
| Facility | | $130.26 | $130.26 | $130.26 |