- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.83 / $206.33 / $206.67
| Facility | | $180.83 | $206.33 | $206.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $180.83 / $232.50
| Professional | | $172.22 | $180.83 | $232.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.73 / $94.73 / $104.20
| Facility | | $94.73 | $94.73 | $104.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.85 / $172.22 / $172.22
| Facility | | $94.85 | $172.22 | $172.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $172.22 / $172.22
| Professional | | $172.22 | $172.22 | $172.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.33 / $172.22 / $223.89
| Professional | | $165.33 | $172.22 | $223.89 |