- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.55 / $369.44 / $369.44
| Facility | | $295.55 | $369.44 | $369.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.44 / $369.44 / $370.08
| Professional | | $369.44 | $369.44 | $370.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.28 / $105.78 / $198.68
| Facility | | $93.28 | $105.78 | $198.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.50 / $168.50 / $210.63
| Professional | | $168.50 | $168.50 | $210.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.00 / $369.44 / $406.63
| Facility | | $360.00 | $369.44 | $406.63 |