- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $253.80
| Facility | | $141.60 | $141.60 | $253.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $170.61
| Professional | | $141.60 | $141.60 | $170.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.63 / $154.40 / $156.38
| Facility | | $153.63 | $154.40 | $156.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.59 / $154.16 / $155.55
| Professional | | $130.59 | $154.16 | $155.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.26 / $144.26 / $165.90
| Facility | | $144.26 | $144.26 | $165.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.13 / $140.52 / $173.91
| Professional | | $139.13 | $140.52 | $173.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.51 / $139.66 / $239.70
| Facility | | $121.51 | $139.66 | $239.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.56 / $141.00 / $153.13
| Professional | | $136.56 | $141.00 | $153.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $141.60 / $153.78
| Professional | | $120.36 | $141.60 | $153.78 |