- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.86 / $161.86 / $167.72
| Facility | | $161.86 | $161.86 | $167.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $141.63 / $161.86
| Professional | | $134.88 | $141.63 | $161.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.84 / $148.84 / $148.84
| Facility | | $148.84 | $148.84 | $148.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.63 / $148.84 / $148.84
| Professional | | $141.63 | $148.84 | $148.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.25 / $134.88 / $134.88
| Facility | | $127.25 | $134.88 | $134.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $139.97
| Professional | | $134.88 | $134.88 | $139.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.40 / $134.88 / $138.94
| Professional | | $121.40 | $134.88 | $138.94 |