- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.65 / $167.65 / $167.65
| Facility | | $167.65 | $167.65 | $167.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.65 / $173.93 / $209.56
| Professional | | $167.65 | $173.93 | $209.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.07 / $166.55 / $180.36
| Professional | | $148.07 | $166.55 | $180.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.13 / $178.13 / $178.13
| Professional | | $178.13 | $178.13 | $178.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.65 / $167.65 / $285.01
| Facility | | $167.65 | $167.65 | $285.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.90 / $202.90 / $227.25
| Professional | | $202.90 | $202.90 | $227.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.90 / $202.90 / $220.36
| Professional | | $202.90 | $202.90 | $220.36 |