- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $420.81 / $420.81 / $420.81
| Facility | | $420.81 | $420.81 | $420.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $134.66
| Professional | | $129.47 | $129.47 | $134.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.10 / $129.58 / $136.91
| Facility | | $125.10 | $129.58 | $136.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $129.47
| Professional | | $129.47 | $129.47 | $129.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.15 / $129.47 / $129.47
| Facility | | $122.15 | $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 |