- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.66 / $130.66 / $130.66
| Facility | | $130.66 | $130.66 | $130.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.66 / $134.19 / $148.94
| Professional | | $130.66 | $134.19 | $148.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.66 / $130.66 / $134.19
| Professional | | $130.66 | $130.66 | $134.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.04 / $177.04 / $177.04
| Professional | | $177.04 | $177.04 | $177.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.19 / $134.19 / $175.52
| Professional | | $134.19 | $134.19 | $175.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.19 / $174.66 / $195.02
| Professional | | $134.19 | $174.66 | $195.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.31 / $146.31 / $146.31
| Professional | | $146.31 | $146.31 | $146.31 |