- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.80 / $141.80 / $141.80
| Facility | | $141.80 | $141.80 | $141.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.17 / $141.40 / $151.76
| Professional | | $117.17 | $141.40 | $151.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.83 / $161.94 / $238.24
| Professional | | $125.83 | $161.94 | $238.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.13 / $206.51 / $320.58
| Professional | | $140.13 | $206.51 | $320.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.30 / $168.37 / $284.61
| Professional | | $136.30 | $168.37 | $284.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.17 / $141.80 / $246.24
| Professional | | $117.17 | $141.80 | $246.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.66 / $187.67 / $249.74
| Professional | | $137.66 | $187.67 | $249.74 |