- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.71 / $169.71 / $193.95
| Facility | | $169.71 | $169.71 | $193.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $169.71 / $193.95
| Professional | | $161.62 | $169.71 | $193.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.82 / $173.82 / $173.82
| Professional | | $173.82 | $173.82 | $173.82 |
- 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
- $17.00 / $25.00 / $50.00
| Professional | | $17.00 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.54 / $161.62 / $210.11
| Professional | | $153.54 | $161.62 | $210.11 |