- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.83 / $166.83 / $166.83
| Facility | | $166.83 | $166.83 | $166.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.83 / $166.83 / $177.26
| Professional | | $166.83 | $166.83 | $177.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Facility | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Professional | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.00 / $200.00 / $345.40
| Professional | | $120.00 | $200.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |