- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.46 / $217.46 / $217.46
| Facility | | $217.46 | $217.46 | $217.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.33 / $217.46 / $217.46
| Professional | | $98.33 | $217.46 | $217.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.71 / $366.04 / $690.78
| Facility | | $162.71 | $366.04 | $690.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.63 / $148.29 / $148.29
| Professional | | $118.63 | $148.29 | $148.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.52 / $217.46 / $566.92
| Facility | | $94.52 | $217.46 | $566.92 |