- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.55 / $127.55 / $503.94
| Facility | | $127.55 | $127.55 | $503.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.54 / $127.55 / $242.60
| Professional | | $115.54 | $127.55 | $242.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.47 / $134.47 / $134.47
| Facility | | $134.47 | $134.47 | $134.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.47 / $134.47 / $134.47
| Professional | | $134.47 | $134.47 | $134.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.82 / $121.82 / $121.82
| Facility | | $121.82 | $121.82 | $121.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.00 / $132.00 / $132.00
| Professional | | $132.00 | $132.00 | $132.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.06 / $120.06 / $151.28
| Professional | | $120.06 | $120.06 | $151.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.40 / $116.81 / $116.81
| Professional | | $81.40 | $116.81 | $116.81 |