- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $568.15 / $568.15 / $784.58
| Facility | | $568.15 | $568.15 | $784.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.55 / $437.38 / $568.15
| Professional | | $270.55 | $437.38 | $568.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.08 / $339.98 / $808.93
| Facility | | $293.08 | $339.98 | $808.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $405.82 / $405.82 / $405.82
| Facility | | $405.82 | $405.82 | $405.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.38 / $270.55 / $453.59
| Professional | | $189.38 | $270.55 | $453.59 |