- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.83 / $134.83 / $202.25
| Facility | | $134.83 | $134.83 | $202.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.83 / $134.83 / $148.31
| Professional | | $134.83 | $134.83 | $148.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.43 / $132.43 / $132.43
| Facility | | $132.43 | $132.43 | $132.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.43 / $132.43 / $132.43
| Professional | | $132.43 | $132.43 | $132.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.83 / $148.32 / $148.32
| Facility | | $125.83 | $148.32 | $148.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.32 / $148.32 / $148.32
| Professional | | $148.32 | $148.32 | $148.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.81 / $139.05 / $158.62
| Professional | | $125.81 | $139.05 | $158.62 |