- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.83 / $149.83 / $247.22
| Facility | | $149.83 | $149.83 | $247.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.83 / $149.83 / $202.50
| Professional | | $149.83 | $149.83 | $202.50 |
- 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
- $164.66 / $164.66 / $164.66
| Professional | | $164.66 | $164.66 | $164.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.46 / $352.54 / $623.78
| Facility | | $167.46 | $352.54 | $623.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.02 / $166.13 / $176.27
| Professional | | $147.02 | $166.13 | $176.27 |