- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.45 / $273.45 / $273.45
| Facility | | $273.45 | $273.45 | $273.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.79 / $273.45 / $273.45
| Professional | | $104.79 | $273.45 | $273.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.71 / $392.72 / $751.96
| Facility | | $162.71 | $392.72 | $751.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.35 / $40.44 / $40.44
| Professional | | $32.35 | $40.44 | $40.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $216.00 / $273.45 / $566.92
| Facility | | $216.00 | $273.45 | $566.92 |