- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.60 / $397.62 / $535.79
| Facility | | $141.60 | $397.62 | $535.79 |
- 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
- $141.00 / $196.98 / $333.07
| Professional | | $141.00 | $196.98 | $333.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.59 / $133.59 / $141.60
| Facility | | $133.59 | $133.59 | $141.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $141.60
| Professional | | $120.36 | $120.36 | $141.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.86 / $141.60 / $229.50
| Professional | | $128.86 | $141.60 | $229.50 |