- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.57 / $187.57 / $187.57
| Facility | | $187.57 | $187.57 | $187.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.54 / $187.57 / $187.57
| Professional | | $176.54 | $187.57 | $187.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.57 / $194.92 / $205.96
| Facility | | $187.57 | $194.92 | $205.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.60 / $198.60 / $198.60
| Professional | | $198.60 | $198.60 | $198.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.85 / $187.57 / $215.20
| Facility | | $174.85 | $187.57 | $215.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.57 / $187.57 / $187.57
| Professional | | $187.57 | $187.57 | $187.57 |