- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.20 / $180.20 / $180.20
| Facility | | $180.20 | $180.20 | $180.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.20 / $180.20 / $198.21
| Professional | | $180.20 | $180.20 | $198.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.03 / $43.72 / $58.82
| Facility | | $36.03 | $43.72 | $58.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Facility | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $238.31
| Professional | | $203.81 | $203.81 | $238.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $205.63 / $218.36
| Professional | | $181.97 | $205.63 | $218.36 |