- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.24 / $141.24 / $176.55
| Facility | | $141.24 | $141.24 | $176.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.24 / $141.24 / $176.55
| Professional | | $141.24 | $141.24 | $176.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $178.58 / $210.09 / $243.59
| Facility | | $178.58 | $210.09 | $243.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.55 / $176.55 / $176.55
| Professional | | $176.55 | $176.55 | $176.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.24 / $176.55 / $210.72
| Facility | | $141.24 | $176.55 | $210.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.80 / $136.80 / $173.02
| Professional | | $136.80 | $136.80 | $173.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.80 / $136.80 / $218.88
| Professional | | $136.80 | $136.80 | $218.88 |