- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.85 / $344.85 / $686.97
| Facility | | $344.85 | $344.85 | $686.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.83 / $344.85 / $365.38
| Professional | | $299.83 | $344.85 | $365.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.41 / $53.43 / $53.83
| Professional | | $44.41 | $53.43 | $53.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.45 / $110.54 / $139.00
| Professional | | $109.45 | $110.54 | $139.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.85 / $344.85 / $586.25
| Facility | | $344.85 | $344.85 | $586.25 |