- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.02 / $140.68 / $194.63
| Facility | | $139.02 | $140.68 | $194.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.02 / $140.68 / $140.68
| Professional | | $139.02 | $140.68 | $140.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.90 / $85.54 / $125.12
| Facility | | $72.90 | $85.54 | $125.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.12 / $125.12 / $127.62
| Professional | | $125.12 | $125.12 | $127.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.58 / $119.58 / $140.68
| Facility | | $119.58 | $119.58 | $140.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.58 / $119.58 / $119.58
| Professional | | $119.58 | $119.58 | $119.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.24 / $117.24 / $139.28
| Professional | | $117.24 | $117.24 | $139.28 |