- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $177.83
| Facility | | $141.25 | $141.25 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $147.91 / $177.83
| Professional | | $141.25 | $147.91 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $147.91 / $186.21
| Professional | | $128.82 | $147.91 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $151.36 / $181.97
| Professional | | $147.91 | $151.36 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $169.82 / $251.19
| Facility | | $141.25 | $169.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $181.97
| Professional | | $162.18 | $162.18 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $154.88 / $218.78
| Professional | | $125.89 | $154.88 | $218.78 |