- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $413.84 / $517.29 / $517.29
| Facility | | $413.84 | $517.29 | $517.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.29 / $517.29 / $517.29
| Professional | | $517.29 | $517.29 | $517.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.09 / $74.70 / $108.21
| Facility | | $55.09 | $74.70 | $108.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.88 / $105.78 / $434.76
| Facility | | $103.88 | $105.78 | $434.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $465.57 / $517.29 / $543.16
| Facility | | $465.57 | $517.29 | $543.16 |