- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $147.91 / $173.78
| Professional | | $138.04 | $147.91 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $144.54 / $169.82
| Professional | | $114.82 | $144.54 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Facility | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $147.91 / $234.42
| Professional | | $138.04 | $147.91 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $144.54 / $173.78
| Professional | | $123.03 | $144.54 | $173.78 |