- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.25 / $202.32 / $202.32
| Facility | | $138.25 | $202.32 | $202.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.25 / $143.31 / $202.32
| Professional | | $138.25 | $143.31 | $202.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.45 / $126.45 / $126.45
| Facility | | $126.45 | $126.45 | $126.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Facility | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Professional | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.45 / $126.45 / $140.50
| Professional | | $126.45 | $126.45 | $140.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $140.50 / $179.84
| Professional | | $134.88 | $140.50 | $179.84 |