- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $191.29 / $191.29 / $218.62
| Facility | | $191.29 | $191.29 | $218.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.18 / $191.29 / $218.62
| Professional | | $182.18 | $191.29 | $218.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.32 / $5.32 / $5.32
| Professional | | $5.32 | $5.32 | $5.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.18 / $182.18 / $182.18
| Facility | | $182.18 | $182.18 | $182.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.18 / $182.18 / $182.18
| Professional | | $182.18 | $182.18 | $182.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.07 / $182.18 / $236.83
| Professional | | $173.07 | $182.18 | $236.83 |