- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.94 / $145.94 / $213.56
| Facility | | $145.94 | $145.94 | $213.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.38 / $151.27 / $213.56
| Professional | | $142.38 | $151.27 | $213.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.27 / $151.27 / $151.27
| Facility | | $151.27 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.27 / $151.27 / $151.27
| Professional | | $151.27 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.25 / $45.00 / $50.00
| Professional | | $38.25 | $45.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.69 / $161.79 / $210.33
| Professional | | $153.69 | $161.79 | $210.33 |