- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.87 / $192.36 / $192.36
| Facility | | $187.87 | $192.36 | $192.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.36 / $192.36 / $192.36
| Professional | | $192.36 | $192.36 | $192.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.45 / $217.79 / $236.90
| Facility | | $182.45 | $217.79 | $236.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.83 / $165.83 / $165.83
| Professional | | $165.83 | $165.83 | $165.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.61 / $309.38 / $444.16
| Facility | | $223.61 | $309.38 | $444.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.83 / $165.83 / $165.83
| Professional | | $165.83 | $165.83 | $165.83 |