- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.76 / $273.45 / $273.45
| Facility | | $218.76 | $273.45 | $273.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.60 / $273.45 / $273.45
| Professional | | $237.60 | $273.45 | $273.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.78 / $133.59 / $331.33
| Facility | | $105.78 | $133.59 | $331.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.79 / $273.45 / $273.45
| Facility | | $104.79 | $273.45 | $273.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.93 / $64.93 / $64.93
| Facility | | $64.93 | $64.93 | $64.93 |