- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.93 / $186.93 / $186.93
| Facility | | $186.93 | $186.93 | $186.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.33 / $186.93 / $310.85
| Professional | | $180.33 | $186.93 | $310.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.60 / $253.15 / $340.57
| Facility | | $208.60 | $253.15 | $340.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.26 / $183.26 / $183.26
| Professional | | $183.26 | $183.26 | $183.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.93 / $186.93 / $186.93
| Facility | | $186.93 | $186.93 | $186.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.80 / $186.93 / $186.93
| Professional | | $11.80 | $186.93 | $186.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.26 / $183.26 / $183.26
| Professional | | $183.26 | $183.26 | $183.26 |