- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $275.42
| Facility | | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $275.42 / $275.42
| Professional | | $104.71 | $275.42 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $331.13 / $524.81
| Facility | | $275.42 | $331.13 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $165.96 / $165.96
| Professional | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $831.76 / $954.99
| Facility | | $707.95 | $831.76 | $954.99 |