- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Facility | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Professional | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.16 / $164.16 / $164.16
| Professional | | $164.16 | $164.16 | $164.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.47 / $152.47 / $161.62
| Facility | | $152.47 | $152.47 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $205.84
| Professional | | $161.62 | $161.62 | $205.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.38 / $137.38 / $186.81
| Professional | | $137.38 | $137.38 | $186.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $261.95
| Professional | | $161.62 | $161.62 | $261.95 |