- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.75 / $140.75 / $2,273.52
| Facility | | $140.75 | $140.75 | $2,273.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.75 / $140.75 / $140.75
| Professional | | $140.75 | $140.75 | $140.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.66 / $161.82 / $161.82
| Facility | | $155.66 | $161.82 | $161.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $161.82 / $161.82
| Professional | | $161.82 | $161.82 | $161.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.75 / $140.75 / $140.75
| Facility | | $140.75 | $140.75 | $140.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.75 / $140.75 / $140.75
| Professional | | $140.75 | $140.75 | $140.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.47 / $144.47 / $173.08
| Professional | | $144.47 | $144.47 | $173.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.75 / $140.75 / $140.75
| Professional | | $140.75 | $140.75 | $140.75 |