- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.05 / $360.06 / $540.09
| Facility | | $288.05 | $360.06 | $540.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.39 / $360.06 / $401.62
| Professional | | $289.39 | $360.06 | $401.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.06 / $162.06 / $162.06
| Facility | | $162.06 | $162.06 | $162.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.47 / $81.01 / $242.55
| Facility | | $37.47 | $81.01 | $242.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.01 / $280.01 / $350.02
| Professional | | $280.01 | $280.01 | $350.02 |