- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.83 / $149.83 / $149.83
| Facility | | $149.83 | $149.83 | $149.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.83 / $149.83 / $149.83
| Professional | | $149.83 | $149.83 | $149.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.27 / $176.27 / $176.27
| Professional | | $176.27 | $176.27 | $176.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.66 / $164.66 / $164.66
| Facility | | $164.66 | $164.66 | $164.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.12 / $153.12 / $153.12
| Professional | | $153.12 | $153.12 | $153.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.55 / $166.13 / $211.52
| Professional | | $145.55 | $166.13 | $211.52 |