- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.75 / $373.74 / $373.74
| Facility | | $140.75 | $373.74 | $373.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.75 / $140.75 / $170.31
| Professional | | $140.75 | $140.75 | $170.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.02 / $155.86 / $158.10
| Professional | | $132.02 | $155.86 | $158.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.40 / $144.83 / $179.25
| Professional | | $143.40 | $144.83 | $179.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.75 / $140.75 / $239.28
| Facility | | $140.75 | $140.75 | $239.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.91 / $158.93 / $173.08
| Professional | | $156.91 | $158.93 | $173.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.47 / $158.93 / $163.26
| Professional | | $144.47 | $158.93 | $163.26 |