- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.10 / $151.10 / $300.69
| Facility | | $151.10 | $151.10 | $300.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.10 / $151.10 / $151.10
| Professional | | $151.10 | $151.10 | $151.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $158.56
| Facility | | $158.56 | $158.56 | $158.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.97 / $158.56 / $158.56
| Professional | | $51.97 | $158.56 | $158.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.92 / $151.10 / $216.07
| Facility | | $48.92 | $151.10 | $216.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.44 / $155.44 / $155.44
| Professional | | $155.44 | $155.44 | $155.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.44 / $155.44 / $158.56
| Professional | | $155.44 | $155.44 | $158.56 |