- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $283.95 / $283.95 / $283.95
| Facility | | $283.95 | $283.95 | $283.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.07 / $204.94 / $204.94
| Professional | | $195.07 | $204.94 | $204.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.50 / $160.50 / $160.50
| Facility | | $160.50 | $160.50 | $160.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.73 / $283.73 / $354.66
| Professional | | $283.73 | $283.73 | $354.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.42 / $118.52 / $246.92
| Professional | | $86.42 | $118.52 | $246.92 |