- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $181.97
| Facility | | $162.18 | $162.18 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $218.78
| Professional | | $162.18 | $162.18 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $194.98 / $194.98
| Facility | | $190.55 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $181.97 / $218.78
| Professional | | $162.18 | $181.97 | $218.78 |