- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.92 / $241.92 / $668.16
| Facility | | $241.92 | $241.92 | $668.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.20 / $241.92 / $241.92
| Professional | | $115.20 | $241.92 | $241.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.60 / $289.54 / $574.08
| Facility | | $249.60 | $289.54 | $574.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.80 / $172.80 / $172.80
| Facility | | $172.80 | $172.80 | $172.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.64 / $115.20 / $192.00
| Professional | | $80.64 | $115.20 | $192.00 |