- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.75 / $140.75 / $156.22
| Facility | | $140.75 | $140.75 | $156.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.75 / $140.75 / $156.22
| Professional | | $140.75 | $140.75 | $156.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.70 / $118.79 / $118.79
| Facility | | $66.70 | $118.79 | $118.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.36 / $161.82 / $161.82
| Facility | | $129.36 | $161.82 | $161.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $161.82 / $161.82
| Professional | | $161.82 | $161.82 | $161.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.47 / $160.52 / $173.08
| Professional | | $144.47 | $160.52 | $173.08 |