- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.60 / $108.60 / $150.34
| Facility | | $108.60 | $108.60 | $150.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $151.72
| Professional | | $137.93 | $137.93 | $151.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.60 / $108.60 / $137.93
| Professional | | $108.60 | $108.60 | $137.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Facility | | $137.93 | $137.93 | $137.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Professional | | $137.93 | $137.93 | $137.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.65 / $149.63 / $200.00
| Professional | | $146.65 | $149.63 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $127.38 / $127.38
| Professional | | $127.38 | $127.38 | $127.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Professional | | $137.93 | $137.93 | $137.93 |