- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.31 / $151.31 / $207.53
| Facility | | $151.31 | $151.31 | $207.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.49 / $146.94 / $152.76
| Professional | | $145.49 | $146.94 | $152.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.49 / $145.49 / $145.49
| Professional | | $145.49 | $145.49 | $145.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.49 / $145.49 / $145.49
| Facility | | $145.49 | $145.49 | $145.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.49 / $145.49 / $145.49
| Professional | | $145.49 | $145.49 | $145.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.49 / $145.49 / $215.82
| Professional | | $145.49 | $145.49 | $215.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.36 / $145.49 / $161.49
| Professional | | $138.36 | $145.49 | $161.49 |