- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.00 / $171.00 / $250.25
| Facility | | $171.00 | $171.00 | $250.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.83 / $177.26 / $250.25
| Professional | | $166.83 | $177.26 | $250.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.97 / $218.97 / $240.86
| Facility | | $218.97 | $218.97 | $240.86 |
- 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
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |