- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.54 / $127.54 / $127.54
| Facility | | $127.54 | $127.54 | $127.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.54 / $127.54 / $140.30
| Professional | | $127.54 | $127.54 | $140.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.21 / $371.21 / $371.21
| Facility | | $371.21 | $371.21 | $371.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.46 / $122.46 / $122.46
| Professional | | $122.46 | $122.46 | $122.46 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $121.82 / $140.94 / $216.22
| Professional | | $121.82 | $140.94 | $216.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.54 / $127.54 / $127.54
| Facility | | $127.54 | $127.54 | $127.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.54 / $127.54 / $184.38
| Professional | | $127.54 | $127.54 | $184.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.06 / $120.06 / $174.09
| Professional | | $120.06 | $120.06 | $174.09 |