- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.75 / $237.75 / $237.75
| Facility | | $237.75 | $237.75 | $237.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.18 / $237.75 / $447.24
| Professional | | $155.18 | $237.75 | $447.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.49 / $50.49 / $63.08
| Facility | | $50.49 | $50.49 | $63.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.36 / $48.98 / $50.49
| Professional | | $38.36 | $48.98 | $50.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.98 / $237.75 / $559.04
| Facility | | $213.98 | $237.75 | $559.04 |