- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.21 / $161.32 / $292.24
| Facility | | $139.21 | $161.32 | $292.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $139.21 / $167.79
| Professional | | $139.21 | $139.21 | $167.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.21 / $222.55 / $442.62
| Facility | | $139.21 | $222.55 | $442.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $139.21 / $155.97
| Professional | | $139.21 | $139.21 | $155.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.33 / $139.21 / $139.21
| Facility | | $131.33 | $139.21 | $139.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $139.21 / $144.47
| Professional | | $139.21 | $139.21 | $144.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $139.21 / $165.66
| Professional | | $139.21 | $139.21 | $165.66 |