- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $147.91 / $151.36
| Professional | | $141.25 | $147.91 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.05 / $26.30 / $141.25
| Professional | | $19.05 | $26.30 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $151.36 / $257.04
| Professional | | $134.90 | $151.36 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $128.82 / $162.18
| Professional | | $125.89 | $128.82 | $162.18 |