- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.52 / $171.52 / $171.52
| Facility | | $171.52 | $171.52 | $171.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.52 / $171.52 / $173.66
| Professional | | $171.52 | $171.52 | $173.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.80 / $182.24 / $203.68
| Professional | | $160.80 | $182.24 | $203.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.26 / $227.26 / $227.26
| Facility | | $227.26 | $227.26 | $227.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.24 / $182.24 / $182.24
| Facility | | $182.24 | $182.24 | $182.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.24 / $182.24 / $182.24
| Professional | | $182.24 | $182.24 | $182.24 |