- 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
- $171.52 / $182.24 / $184.38
| Professional | | $171.52 | $182.24 | $184.38 |
- 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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.95 / $184.38 / $236.01
| Facility | | $177.95 | $184.38 | $236.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |