- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.62 / $129.62 / $129.62
| Facility | | $129.62 | $129.62 | $129.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.62 / $134.47 / $162.02
| Professional | | $129.62 | $134.47 | $162.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.50 / $142.27 / $144.31
| Professional | | $120.50 | $142.27 | $144.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.88 / $32.34 / $137.72
| Professional | | $25.88 | $32.34 | $137.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.62 / $168.51 / $230.88
| Facility | | $129.62 | $168.51 | $230.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.91 / $153.91 / $324.04
| Professional | | $153.91 | $153.91 | $324.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.91 / $153.91 / $203.17
| Professional | | $153.91 | $153.91 | $203.17 |