- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.02 / $162.02 / $226.83
| Facility | | $162.02 | $162.02 | $226.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.02 / $162.02 / $162.02
| Professional | | $162.02 | $162.02 | $162.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.77 / $145.77 / $218.66
| Facility | | $145.77 | $145.77 | $218.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.77 / $145.77 / $148.69
| Professional | | $145.77 | $145.77 | $148.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.72 / $137.72 / $137.72
| Facility | | $137.72 | $137.72 | $137.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.72 / $137.72 / $137.72
| Professional | | $137.72 | $137.72 | $137.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.91 / $153.91 / $207.14
| Professional | | $153.91 | $153.91 | $207.14 |