- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.54 / $208.54 / $208.54
| Facility | | $208.54 | $208.54 | $208.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.83 / $166.83 / $208.54
| Professional | | $166.83 | $166.83 | $208.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.26 / $333.00 / $333.00
| Facility | | $177.26 | $333.00 | $333.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Professional | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.83 / $195.19 / $468.79
| Facility | | $166.83 | $195.19 | $468.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.45 / $792.45 / $792.45
| Professional | | $792.45 | $792.45 | $792.45 |