- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.52 / $134.52 / $235.41
| Facility | | $134.52 | $134.52 | $235.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.66 / $134.52 / $137.77
| Professional | | $129.66 | $134.52 | $137.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Facility | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Professional | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $163.61
| Facility | | $162.08 | $162.08 | $163.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.54 / $238.54 / $238.54
| Professional | | $238.54 | $238.54 | $238.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.97 / $162.08 / $162.08
| Professional | | $153.97 | $162.08 | $162.08 |