- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.57 / $187.57 / $187.57
| Facility | | $187.57 | $187.57 | $187.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.54 / $187.57 / $187.57
| Professional | | $176.54 | $187.57 | $187.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.47 / $163.16 / $607.54
| Facility | | $126.47 | $163.16 | $607.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.51 / $160.68 / $177.29
| Professional | | $120.51 | $160.68 | $177.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.57 / $187.57 / $308.68
| Facility | | $187.57 | $187.57 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.57 / $187.57 / $187.57
| Professional | | $187.57 | $187.57 | $187.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.16 / $149.16 / $157.93
| Professional | | $149.16 | $149.16 | $157.93 |