- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.24 / $131.24 / $223.11
| Facility | | $131.24 | $131.24 | $223.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.62 / $131.24 / $134.47
| Professional | | $129.62 | $131.24 | $134.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.72 / $137.72 / $137.72
| Facility | | $137.72 | $137.72 | $137.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.72 / $137.72 / $137.72
| Professional | | $137.72 | $137.72 | $137.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.09 / $131.24 / $162.02
| Facility | | $131.09 | $131.24 | $162.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.74 / $153.91 / $170.54
| Professional | | $107.74 | $153.91 | $170.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.91 / $153.91 / $169.73
| Professional | | $153.91 | $153.91 | $169.73 |