- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.42 / $256.42 / $327.43
| Facility | | $256.42 | $256.42 | $327.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.42 / $327.43 / $388.91
| Professional | | $256.42 | $327.43 | $388.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.57 / $1,709.28 / $1,832.29
| Facility | | $1,370.57 | $1,709.28 | $1,832.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.31 / $310.31 / $310.31
| Professional | | $310.31 | $310.31 | $310.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.42 / $327.43 / $474.38
| Facility | | $256.42 | $327.43 | $474.38 |