- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.45 / $344.45 / $344.45
| Facility | | $344.45 | $344.45 | $344.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.06 / $344.45 / $1,276.92
| Professional | | $100.06 | $344.45 | $1,276.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.95 / $344.45 / $1,025.45
| Facility | | $84.95 | $344.45 | $1,025.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.06 / $344.45 / $1,276.92
| Professional | | $100.06 | $344.45 | $1,276.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.32 / $595.91 / $993.19
| Professional | | $476.32 | $595.91 | $993.19 |