- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.08 / $130.08 / $130.08
| Facility | | $130.08 | $130.08 | $130.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.13 / $130.08 / $130.79
| Professional | | $118.13 | $130.08 | $130.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.42 / $243.60 / $1,403.61
| Facility | | $231.42 | $243.60 | $1,403.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.88 / $236.29 / $243.60
| Professional | | $194.88 | $236.29 | $243.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.17 / $13.17 / $13.17
| Professional | | $13.17 | $13.17 | $13.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.13 / $130.08 / $219.84
| Facility | | $118.13 | $130.08 | $219.84 |