- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $155.38
| Facility | | $141.25 | $141.25 | $155.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $155.37
| Professional | | $141.25 | $141.25 | $155.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.22 / $139.22 / $168.18
| Professional | | $139.22 | $139.22 | $168.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.50 / $148.50 / $148.50
| Facility | | $148.50 | $148.50 | $148.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.50 / $148.50 / $158.96
| Professional | | $148.50 | $148.50 | $158.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $149.72
| Facility | | $141.25 | $141.25 | $149.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.63 / $146.63 / $146.63
| Professional | | $146.63 | $146.63 | $146.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.96 / $158.96 / $246.39
| Professional | | $158.96 | $158.96 | $246.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.01 / $151.01 / $230.49
| Facility | | $151.01 | $151.01 | $230.49 |