- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $129.58
| Facility | | $129.47 | $129.47 | $129.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $222.87
| Professional | | $129.47 | $129.47 | $222.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.66 / $1,813.84 / $2,440.19
| Facility | | $1,494.66 | $1,813.84 | $2,440.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.74 / $129.47 / $129.47
| Professional | | $124.74 | $129.47 | $129.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $129.47
| Facility | | $129.47 | $129.47 | $129.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $129.47
| Professional | | $129.47 | $129.47 | $129.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $129.47
| Professional | | $129.47 | $129.47 | $129.47 |