- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.16 / $131.16 / $131.16
| Facility | | $131.16 | $131.16 | $131.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.15 / $131.16 / $137.72
| Professional | | $131.15 | $131.16 | $137.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.57 / $459.72 / $7,637.32
| Facility | | $196.57 | $459.72 | $7,637.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.16 / $131.16 / $331.66
| Professional | | $131.16 | $131.16 | $331.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.16 / $131.16 / $131.16
| Facility | | $131.16 | $131.16 | $131.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.16 / $131.16 / $131.16
| Professional | | $131.16 | $131.16 | $131.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.16 / $131.16 / $139.03
| Professional | | $131.16 | $131.16 | $139.03 |