- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.24 / $141.24 / $317.79
| Facility | | $141.24 | $141.24 | $317.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.24 / $176.55 / $176.55
| Professional | | $141.24 | $176.55 | $176.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.25 / $155.25 / $194.06
| Professional | | $155.25 | $155.25 | $194.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.24 / $176.55 / $240.11
| Facility | | $141.24 | $176.55 | $240.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.80 / $136.80 / $148.57
| Professional | | $136.80 | $136.80 | $148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.28 / $136.80 / $150.47
| Professional | | $116.28 | $136.80 | $150.47 |