- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.60 / $137.93 / $137.93
| Facility | | $108.60 | $137.93 | $137.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $142.06
| Professional | | $137.93 | $137.93 | $142.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.52 / $128.52 / $128.52
| Facility | | $128.52 | $128.52 | $128.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.52 / $128.52 / $137.93
| Professional | | $128.52 | $128.52 | $137.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.12 / $130.12 / $215.31
| Facility | | $130.12 | $130.12 | $215.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Professional | | $137.93 | $137.93 | $137.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.60 / $146.19 / $247.84
| Facility | | $108.60 | $146.19 | $247.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.34 / $151.72 / $195.86
| Professional | | $150.34 | $151.72 | $195.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Professional | | $137.93 | $137.93 | $137.93 |