- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.72 / $158.72 / $181.40
| Facility | | $158.72 | $158.72 | $181.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $158.72 / $181.40
| Professional | | $151.16 | $158.72 | $181.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.08 / $104.08 / $104.08
| Professional | | $104.08 | $104.08 | $104.08 |
- 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 / $207.74
| Professional | | $151.16 | $151.16 | $207.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.52 / $151.16 / $196.52
| Professional | | $131.52 | $151.16 | $196.52 |