- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.39 / $320.39 / $320.39
| Facility | | $320.39 | $320.39 | $320.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.18 / $320.39 / $320.39
| Professional | | $253.18 | $320.39 | $320.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,935.29 / $3,005.71 / $4,765.84
| Facility | | $1,935.29 | $3,005.71 | $4,765.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.39 / $320.39 / $387.68
| Facility | | $320.39 | $320.39 | $387.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.89 / $284.89 / $284.89
| Professional | | $284.89 | $284.89 | $284.89 |