- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $158.49
| Facility | | $104.71 | $104.71 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $245.47 / $275.42
| Professional | | $104.71 | $245.47 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $245.47
| Facility | | $177.83 | $177.83 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.15 / $75.86 / $489.78
| Facility | | $37.15 | $75.86 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $269.15 / $501.19
| Facility | | $208.93 | $269.15 | $501.19 |