- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.50 / $150.50 / $150.50
| Facility | | $150.50 | $150.50 | $150.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.53 / $150.53 / $188.16
| Professional | | $150.53 | $150.53 | $188.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.35 / $225.62 / $353.59
| Facility | | $181.35 | $225.62 | $353.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.35 / $225.62 / $357.06
| Professional | | $181.35 | $225.62 | $357.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.84 / $225.62 / $357.06
| Facility | | $184.84 | $225.62 | $357.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.35 / $225.62 / $304.83
| Professional | | $181.35 | $225.62 | $304.83 |