- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $257.04 / $323.59
| Facility | | $257.04 | $257.04 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $323.59 / $389.05
| Professional | | $316.23 | $323.59 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,412.54 / $1,819.70
| Facility | | $1,348.96 | $1,412.54 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $331.13 / $537.03
| Facility | | $257.04 | $331.13 | $537.03 |