- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $151.36
| Facility | | $138.04 | $138.04 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $190.55
| Professional | | $138.04 | $138.04 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $177.83 / $177.83
| Facility | | $173.78 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Professional | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $151.36 / $151.36
| Facility | | $138.04 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $154.88 / $199.53
| Professional | | $138.04 | $154.88 | $199.53 |