- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.46 / $260.95 / $469.71
| Facility | | $217.46 | $260.95 | $469.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.46 / $217.46 / $217.46
| Professional | | $217.46 | $217.46 | $217.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.58 / $143.86 / $451.85
| Facility | | $61.58 | $143.86 | $451.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.52 / $217.46 / $217.46
| Facility | | $94.52 | $217.46 | $217.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.33 / $132.33 / $132.33
| Professional | | $132.33 | $132.33 | $132.33 |