- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $364.45 / $364.45 / $364.45
| Facility | | $364.45 | $364.45 | $364.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.54 / $162.27 / $299.47
| Professional | | $116.54 | $162.27 | $299.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.73 / $246.73 / $246.73
| Professional | | $246.73 | $246.73 | $246.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.26 / $156.72 / $345.89
| Professional | | $67.26 | $156.72 | $345.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.02 / $180.42 / $432.85
| Professional | | $118.02 | $180.42 | $432.85 |