- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.77 / $211.86 / $211.86
| Facility | | $144.77 | $211.86 | $211.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.77 / $150.07 / $211.86
| Professional | | $144.77 | $150.07 | $211.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.00 / $165.00 / $181.50
| Facility | | $165.00 | $165.00 | $181.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.68 / $164.68 / $164.68
| Facility | | $164.68 | $164.68 | $164.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $17.00 / $20.00
| Professional | | $17.00 | $17.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.33 / $136.80 / $175.10
| Professional | | $131.33 | $136.80 | $175.10 |