- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.42 / $164.42 / $164.42
| Facility | | $164.42 | $164.42 | $164.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.42 / $164.42 / $164.42
| Professional | | $164.42 | $164.42 | $164.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.62 / $219.62 / $219.62
| Professional | | $219.62 | $219.62 | $219.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.98 / $226.11 / $255.93
| Facility | | $182.98 | $226.11 | $255.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.19 / $185.79 / $197.30
| Professional | | $156.19 | $185.79 | $197.30 |