- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.66 / $166.40 / $170.63
| Facility | | $138.66 | $166.40 | $170.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.66 / $139.21 / $144.78
| Professional | | $138.66 | $139.21 | $144.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.43 / $250.58 / $608.45
| Facility | | $166.43 | $250.58 | $608.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $139.21 / $139.21
| Professional | | $139.21 | $139.21 | $139.21 |
- 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 / $139.21
| Professional | | $139.21 | $139.21 | $139.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $139.21 / $233.27
| Professional | | $139.21 | $139.21 | $233.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $139.21 / $147.56
| Professional | | $139.21 | $139.21 | $147.56 |