- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.72 / $151.27 / $151.27
| Facility | | $147.72 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.38 / $147.72 / $151.27
| Professional | | $142.38 | $147.72 | $151.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.25 / $16.11 / $43.92
| Facility | | $12.25 | $16.11 | $43.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.60 / $77.05 / $142.38
| Professional | | $35.60 | $77.05 | $142.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.27 / $151.27 / $151.27
| Facility | | $151.27 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.27 / $151.27 / $151.27
| Professional | | $151.27 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.79 / $161.79 / $186.06
| Professional | | $161.79 | $161.79 | $186.06 |