- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.54 / $199.03 / $199.03
| Facility | | $169.54 | $199.03 | $199.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.11 / $142.10 / $160.47
| Professional | | $134.11 | $142.10 | $160.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $635.48 / $635.48 / $635.48
| Facility | | $635.48 | $635.48 | $635.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.20 / $172.78 / $261.35
| Professional | | $110.20 | $172.78 | $261.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.69 / $154.09 / $391.17
| Professional | | $100.69 | $154.09 | $391.17 |