- 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
- $161.82 / $161.82 / $161.82
| Professional | | $161.82 | $161.82 | $161.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.06 / $201.36 / $253.13
| Facility | | $176.06 | $201.36 | $253.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.26 / $163.26 / $173.38
| Professional | | $137.26 | $163.26 | $173.38 |