- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.23 / $256.23 / $256.23
| Facility | | $256.23 | $256.23 | $256.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.97 / $146.97 / $189.26
| Professional | | $146.97 | $146.97 | $189.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.36 / $74.36 / $74.36
| Facility | | $74.36 | $74.36 | $74.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.40 / $189.68 / $647.09
| Professional | | $134.40 | $189.68 | $647.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.54 / $236.13 / $519.49
| Professional | | $125.54 | $236.13 | $519.49 |