- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.51 / $197.51 / $272.75
| Facility | | $197.51 | $197.51 | $272.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.05 / $186.53 / $197.51
| Professional | | $94.05 | $186.53 | $197.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.89 / $118.19 / $281.22
| Facility | | $101.89 | $118.19 | $281.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.08 / $141.08 / $156.75
| Facility | | $141.08 | $141.08 | $156.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.84 / $94.05 / $156.75
| Professional | | $65.84 | $94.05 | $156.75 |