- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $162.97
| Facility | | $162.97 | $162.97 | $162.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $265.94
| Professional | | $162.97 | $162.97 | $265.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.09 / $177.29 / $238.52
| Facility | | $146.09 | $177.29 | $238.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $162.97
| Professional | | $162.97 | $162.97 | $162.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Facility | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $238.31
| Professional | | $203.81 | $203.81 | $238.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $184.17 / $218.36
| Professional | | $162.97 | $184.17 | $218.36 |