- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.38 / $147.72 / $147.72
| Facility | | $142.38 | $147.72 | $147.72 |
- 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
- $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
- $75.64 / $151.27 / $151.27
| Professional | | $75.64 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $138.44 / $166.31
| Professional | | $50.00 | $138.44 | $166.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.79 / $161.79 / $161.79
| Professional | | $161.79 | $161.79 | $161.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.68 / $10.68 / $10.68
| Professional | | $10.68 | $10.68 | $10.68 |