- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.35 / $233.35 / $322.25
| Facility | | $233.35 | $233.35 | $322.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.12 / $179.64 / $233.35
| Professional | | $111.12 | $179.64 | $233.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.38 / $139.63 / $332.25
| Facility | | $120.38 | $139.63 | $332.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.68 / $166.68 / $166.68
| Facility | | $166.68 | $166.68 | $166.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.78 / $111.12 / $185.20
| Professional | | $77.78 | $111.12 | $185.20 |