- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.47 / $122.47 / $183.71
| Facility | | $122.47 | $122.47 | $183.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.47 / $122.47 / $246.23
| Professional | | $122.47 | $122.47 | $246.23 |
- 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
- $16.10 / $72.45 / $235.08
| Facility | | $16.10 | $72.45 | $235.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.26 / $130.26 / $130.26
| Facility | | $130.26 | $130.26 | $130.26 |