- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.83 / $166.83 / $166.83
| Facility | | $166.83 | $166.83 | $166.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.83 / $166.83 / $173.09
| Professional | | $166.83 | $166.83 | $173.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.41 / $156.41 / $166.84
| Professional | | $156.41 | $156.41 | $166.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $605.35 / $605.35 / $605.35
| Facility | | $605.35 | $605.35 | $605.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.41 / $497.25 / $605.35
| Professional | | $448.41 | $497.25 | $605.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Facility | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Professional | | $177.26 | $177.26 | $177.26 |