- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.26 / $164.26 / $273.98
| Facility | | $164.26 | $164.26 | $273.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.26 / $164.26 / $164.26
| Professional | | $164.26 | $164.26 | $164.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.96 / $181.80 / $206.39
| Facility | | $158.96 | $181.80 | $206.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $141.60
| Professional | | $141.60 | $141.60 | $141.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $328.08
| Facility | | $141.60 | $141.60 | $328.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $141.60
| Professional | | $141.60 | $141.60 | $141.60 |