- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $172.40
| Facility | | $172.40 | $172.40 | $172.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.34 / $172.40 / $172.40
| Professional | | $168.34 | $172.40 | $172.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.68 / $192.68 / $192.68
| Facility | | $192.68 | $192.68 | $192.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.68 / $192.68 / $192.68
| Professional | | $192.68 | $192.68 | $192.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.16 / $172.40 / $172.40
| Facility | | $145.16 | $172.40 | $172.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $172.40
| Professional | | $172.40 | $172.40 | $172.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.90 / $202.82 / $208.90
| Professional | | $182.90 | $202.82 | $208.90 |