- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.67 / $241.67 / $241.67
| Facility | | $241.67 | $241.67 | $241.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.36 / $74.36 / $77.33
| Professional | | $74.36 | $74.36 | $77.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.45 / $74.45 / $78.67
| Facility | | $74.45 | $74.45 | $78.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.36 / $74.36 / $74.36
| Professional | | $74.36 | $74.36 | $74.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.36 / $74.36 / $74.36
| Facility | | $74.36 | $74.36 | $74.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.36 / $74.36 / $74.36
| Professional | | $74.36 | $74.36 | $74.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.36 / $74.36 / $82.78
| Professional | | $74.36 | $74.36 | $82.78 |