- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.60 / $166.73 / $305.40
| Facility | | $141.60 | $166.73 | $305.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $143.02 / $194.45
| Professional | | $141.60 | $143.02 | $194.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.60 / $229.25 / $443.15
| Facility | | $141.60 | $229.25 | $443.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $141.60
| Professional | | $141.60 | $141.60 | $141.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.59 / $141.60 / $141.60
| Facility | | $133.59 | $141.60 | $141.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $141.60
| Professional | | $141.60 | $141.60 | $141.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $158.18
| Professional | | $141.60 | $141.60 | $158.18 |