- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.55 / $295.55 / $369.44
| Facility | | $295.55 | $295.55 | $369.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.43 / $369.44 / $369.44
| Professional | | $336.43 | $369.44 | $369.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.00 / $117.71 / $158.36
| Facility | | $97.00 | $117.71 | $158.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.84 / $84.84 / $108.46
| Professional | | $84.84 | $84.84 | $108.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.76 / $132.22 / $340.36
| Facility | | $39.76 | $132.22 | $340.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.50 / $168.50 / $210.63
| Professional | | $168.50 | $168.50 | $210.63 |