- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $141.25 / $239.88
| Professional | | $138.04 | $141.25 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $190.55 / $190.55
| Professional | | $162.18 | $190.55 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $199.53
| Professional | | $141.25 | $141.25 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $269.15
| Facility | | $141.25 | $141.25 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $154.88
| Professional | | $141.25 | $141.25 | $154.88 |