- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $180.90
| Facility | | $162.97 | $162.97 | $180.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $180.90
| Professional | | $162.97 | $162.97 | $180.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.36 / $141.36 / $141.36
| Facility | | $141.36 | $141.36 | $141.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.27 / $203.81 / $203.81
| Facility | | $190.27 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Professional | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $181.07 / $218.36
| Professional | | $162.97 | $181.07 | $218.36 |