- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.55 / $176.55 / $176.55
| Facility | | $176.55 | $176.55 | $176.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.54 / $176.55 / $176.55
| Professional | | $146.54 | $176.55 | $176.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.25 / $155.25 / $194.06
| Professional | | $155.25 | $155.25 | $194.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $201.97 / $237.71 / $435.39
| Facility | | $201.97 | $237.71 | $435.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.80 / $136.80 / $150.47
| Professional | | $136.80 | $136.80 | $150.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.59 / $186.59 / $267.12
| Professional | | $186.59 | $186.59 | $267.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.80 / $136.80 / $150.47
| Professional | | $136.80 | $136.80 | $150.47 |