- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.55 / $191.33 / $250.54
| Facility | | $127.55 | $191.33 | $250.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.54 / $127.55 / $140.30
| Professional | | $127.54 | $127.55 | $140.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.06 / $120.06 / $120.06
| Facility | | $120.06 | $120.06 | $120.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.06 / $120.06 / $120.06
| Professional | | $120.06 | $120.06 | $120.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.12 / $134.47 / $134.47
| Facility | | $116.12 | $134.47 | $134.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.47 / $134.47 / $134.47
| Professional | | $134.47 | $134.47 | $134.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.06 / $126.06 / $135.66
| Professional | | $114.06 | $126.06 | $135.66 |