- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $204.81
| Facility | | $141.25 | $141.25 | $204.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $237.05
| Professional | | $141.25 | $141.25 | $237.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.08 / $182.63 / $371.64
| Facility | | $146.08 | $182.63 | $371.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.84 / $143.63 / $145.09
| Professional | | $137.84 | $143.63 | $145.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.75 / $148.50 / $165.94
| Professional | | $132.75 | $148.50 | $165.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.49 / $230.49 / $268.38
| Facility | | $230.49 | $230.49 | $268.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.96 / $174.86 / $190.75
| Professional | | $158.96 | $174.86 | $190.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.44 / $140.44 / $140.44
| Facility | | $140.44 | $140.44 | $140.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.96 / $174.86 / $187.57
| Professional | | $158.96 | $174.86 | $187.57 |