- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.54 / $176.54 / $185.36
| Facility | | $176.54 | $176.54 | $185.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.54 / $176.54 / $187.57
| Professional | | $176.54 | $176.54 | $187.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $222.50 / $374.06 / $888.53
| Facility | | $222.50 | $374.06 | $888.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.63 / $187.57 / $187.57
| Professional | | $158.63 | $187.57 | $187.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.96 / $186.62 / $186.62
| Facility | | $167.96 | $186.62 | $186.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.54 / $186.62 / $223.94
| Professional | | $176.54 | $186.62 | $223.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $100.00
| Professional | | $30.00 | $30.00 | $100.00 |