- 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 / $180.20
| Professional | | $180.20 | $180.20 | $180.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.20 / $180.20 / $180.20
| Professional | | $180.20 | $180.20 | $180.20 |
- 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
- $254.68 / $254.68 / $254.68
| Professional | | $254.68 | $254.68 | $254.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.15 / $205.63 / $262.02
| Professional | | $180.15 | $205.63 | $262.02 |