- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.53 / $170.53 / $170.53
| Facility | | $170.53 | $170.53 | $170.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $55.10
| Professional | | $52.47 | $52.47 | $55.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.62 / $52.04 / $54.99
| Facility | | $51.62 | $52.04 | $54.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $52.47
| Professional | | $52.47 | $52.47 | $52.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $52.47
| Facility | | $52.47 | $52.47 | $52.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $52.47
| Professional | | $52.47 | $52.47 | $52.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $58.41
| Professional | | $52.47 | $52.47 | $58.41 |