- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.68 / $145.68 / $145.68
| Facility | | $145.68 | $145.68 | $145.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $145.68 / $145.68
| Professional | | $134.88 | $145.68 | $145.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.25 / $127.25 / $134.88
| Facility | | $127.25 | $127.25 | $134.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $134.88
| Professional | | $134.88 | $134.88 | $134.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.16 / $155.58 / $211.88
| Facility | | $148.16 | $155.58 | $211.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.84 / $137.19 / $202.67
| Professional | | $131.84 | $137.19 | $202.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.63 / $134.88 / $148.74
| Professional | | $129.63 | $134.88 | $148.74 |