- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.70 / $167.70 / $251.55
| Facility | | $167.70 | $167.70 | $251.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.70 / $167.70 / $217.46
| Professional | | $167.70 | $167.70 | $217.46 |
- 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 / $72.45 / $150.69
| Facility | | $37.47 | $72.45 | $150.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.26 / $130.26 / $130.26
| Facility | | $130.26 | $130.26 | $130.26 |