- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.58 / $177.58 / $604.16
| Facility | | $177.58 | $177.58 | $604.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.58 / $177.58 / $180.86
| Professional | | $177.58 | $177.58 | $180.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.62 / $219.62 / $219.62
| Facility | | $219.62 | $219.62 | $219.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.96 / $219.62 / $219.62
| Professional | | $185.96 | $219.62 | $219.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.12 / $186.46 / $253.94
| Facility | | $134.12 | $186.46 | $253.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.19 / $194.02 / $224.00
| Professional | | $156.19 | $194.02 | $224.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.19 / $194.02 / $235.16
| Professional | | $156.19 | $194.02 | $235.16 |