- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.50 / $161.50 / $252.67
| Facility | | $161.50 | $161.50 | $252.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.00 / $161.50 / $161.50
| Professional | | $152.00 | $161.50 | $161.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.73 / $65.92 / $81.84
| Professional | | $52.73 | $65.92 | $81.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.50 / $161.50 / $161.50
| Facility | | $161.50 | $161.50 | $161.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.50 / $161.50 / $161.50
| Professional | | $161.50 | $161.50 | $161.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.06 / $156.06 / $156.06
| Professional | | $156.06 | $156.06 | $156.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.13 / $167.51 / $175.89
| Professional | | $159.13 | $167.51 | $175.89 |