- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.81 / $175.81 / $257.27
| Facility | | $175.81 | $175.81 | $257.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.52 / $182.24 / $257.27
| Professional | | $171.52 | $182.24 | $257.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.12 / $225.12 / $247.63
| Facility | | $225.12 | $225.12 | $247.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.24 / $182.24 / $182.24
| Facility | | $182.24 | $182.24 | $182.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.24 / $182.24 / $182.24
| Professional | | $182.24 | $182.24 | $182.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |