- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.36 / $513.36 / $708.93
| Facility | | $513.36 | $513.36 | $708.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.46 / $513.36 / $513.36
| Professional | | $244.46 | $513.36 | $513.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $264.83 / $307.20 / $730.93
| Facility | | $264.83 | $307.20 | $730.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $366.69 / $366.69 / $366.69
| Facility | | $366.69 | $366.69 | $366.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.12 / $244.46 / $407.43
| Professional | | $171.12 | $244.46 | $407.43 |