- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.72 / $147.72 / $151.27
| Facility | | $147.72 | $147.72 | $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
- Professional
- Modifier
- Low / Median / High Price
- $77.05 / $77.05 / $142.38
| Professional | | $77.05 | $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
- $127.38 / $177.97 / $222.92
| Professional | | $127.38 | $177.97 | $222.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $127.38 / $191.07
| Professional | | $127.38 | $127.38 | $191.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.79 / $161.79 / $161.79
| Professional | | $161.79 | $161.79 | $161.79 |