- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.12 / $311.12 / $429.64
| Facility | | $311.12 | $311.12 | $429.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.15 / $311.12 / $311.12
| Professional | | $148.15 | $311.12 | $311.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.50 / $186.18 / $442.98
| Facility | | $160.50 | $186.18 | $442.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.73 / $283.73 / $354.66
| Professional | | $283.73 | $283.73 | $354.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.71 / $148.15 / $246.92
| Professional | | $103.71 | $148.15 | $246.92 |