- 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
- $245.47 / $275.42 / $724.44
| Professional | | $245.47 | $275.42 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $177.83 / $346.74
| Facility | | $138.04 | $177.83 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $275.42 / $524.81
| Facility | | $213.80 | $275.42 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.88 / $229.09 / $645.65
| Facility | | $154.88 | $229.09 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $109.65 / $109.65
| Professional | | $26.92 | $109.65 | $109.65 |