- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.21 / $421.69 / $431.65
| Facility | | $157.21 | $421.69 | $431.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $152.68 / $173.84
| Professional | | $151.16 | $152.68 | $173.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $151.16
| Professional | | $151.16 | $151.16 | $151.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $151.16
| Facility | | $151.16 | $151.16 | $151.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $151.16
| Professional | | $151.16 | $151.16 | $151.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $306.61
| Professional | | $151.16 | $151.16 | $306.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.61 / $151.16 / $158.72
| Professional | | $143.61 | $151.16 | $158.72 |