- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.60 / $164.60 / $182.70
| Facility | | $164.60 | $164.60 | $182.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.59 / $164.60 / $182.70
| Professional | | $164.59 | $164.60 | $182.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.61 / $110.61 / $121.66
| Facility | | $110.61 | $110.61 | $121.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.41 / $175.41 / $175.41
| Facility | | $175.41 | $175.41 | $175.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.41 / $175.41 / $175.41
| Professional | | $175.41 | $175.41 | $175.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $17.00 / $20.00
| Professional | | $17.00 | $17.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.69 / $174.09 / $187.09
| Professional | | $156.69 | $174.09 | $187.09 |