- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.20 / $180.20 / $200.02
| Facility | | $180.20 | $180.20 | $200.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.20 / $180.20 / $200.02
| Professional | | $180.20 | $180.20 | $200.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.36 / $141.36 / $141.36
| Facility | | $141.36 | $141.36 | $141.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $178.83 / $203.81 / $203.81
| Facility | | $178.83 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Professional | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $205.63 / $218.36
| Professional | | $181.97 | $205.63 | $218.36 |