- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.76 / $137.76 / $137.76
| Facility | | $137.76 | $137.76 | $137.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.75 / $137.76 / $140.30
| Professional | | $137.75 | $137.76 | $140.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.47 / $134.47 / $134.47
| Facility | | $134.47 | $134.47 | $134.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.78 / $134.47 / $134.47
| Professional | | $86.78 | $134.47 | $134.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.35 / $137.76 / $512.54
| Facility | | $110.35 | $137.76 | $512.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.06 / $134.99 / $144.07
| Professional | | $114.06 | $134.99 | $144.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.06 / $134.99 / $144.07
| Professional | | $114.06 | $134.99 | $144.07 |