- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $212.71
| Facility | | $177.26 | $177.26 | $212.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.92 / $177.26 / $177.26
| Professional | | $168.92 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.84 / $166.84 / $166.84
| Professional | | $166.84 | $166.84 | $166.84 |
- 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 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $235.19 / $293.99
| Professional | | $177.26 | $235.19 | $293.99 |