- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.68 / $262.68 / $675.45
| Facility | | $262.68 | $262.68 | $675.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.68 / $352.74 / $352.74
| Professional | | $262.68 | $352.74 | $352.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.17 / $431.17 / $632.98
| Professional | | $431.17 | $431.17 | $632.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.92 / $270.18 / $675.45
| Facility | | $83.92 | $270.18 | $675.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.81 / $157.61 / $750.50
| Professional | | $47.81 | $157.61 | $750.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.81 / $450.30 / $720.86
| Professional | | $47.81 | $450.30 | $720.86 |