- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.78 / $416.78 / $437.62
| Facility | | $416.78 | $416.78 | $437.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.78 / $416.78 / $416.78
| Professional | | $416.78 | $416.78 | $416.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $541.80 / $562.65 / $562.65
| Facility | | $541.80 | $562.65 | $562.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.78 / $416.78 / $416.78
| Facility | | $416.78 | $416.78 | $416.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $42.50
| Professional | | $17.00 | $20.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.07 / $250.07 / $708.53
| Professional | | $175.07 | $250.07 | $708.53 |