- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.66 / $129.66 / $129.66
| Facility | | $129.66 | $129.66 | $129.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.66 / $134.52 / $162.08
| Professional | | $129.66 | $134.52 | $162.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.91 / $280.91 / $323.04
| Facility | | $280.91 | $280.91 | $323.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.36 / $181.16 / $224.20
| Professional | | $179.36 | $181.16 | $224.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.66 / $134.52 / $220.42
| Facility | | $129.66 | $134.52 | $220.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $181.53
| Professional | | $162.08 | $162.08 | $181.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $181.53
| Professional | | $162.08 | $162.08 | $181.53 |