- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.47 / $118.47 / $185.11
| Facility | | $118.47 | $118.47 | $185.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.47 / $185.11 / $216.38
| Professional | | $118.47 | $185.11 | $216.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.82 / $163.82 / $163.82
| Facility | | $163.82 | $163.82 | $163.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.82 / $163.82 / $163.82
| Professional | | $163.82 | $163.82 | $163.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.47 / $166.47 / $166.47
| Facility | | $166.47 | $166.47 | $166.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.52 / $121.52 / $166.47
| Professional | | $121.52 | $121.52 | $166.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.31 / $105.47 / $166.82
| Professional | | $70.31 | $105.47 | $166.82 |