- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.83 / $154.83 / $154.83
| Facility | | $154.83 | $154.83 | $154.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.83 / $154.83 / $154.83
| Professional | | $154.83 | $154.83 | $154.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $158.56
| Professional | | $158.56 | $158.56 | $158.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.78 / $330.37 / $474.30
| Facility | | $238.78 | $330.37 | $474.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.44 / $155.44 / $155.44
| Professional | | $155.44 | $155.44 | $155.44 |