- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.97 / $234.74 / $1,375.70
| Facility | | $135.97 | $234.74 | $1,375.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.36 / $123.36 / $135.97
| Professional | | $123.36 | $123.36 | $135.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.99 / $156.46 / $156.46
| Professional | | $132.99 | $156.46 | $156.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.38 / $116.38 / $116.38
| Facility | | $116.38 | $116.38 | $116.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.36 / $123.36 / $174.57
| Professional | | $123.36 | $123.36 | $174.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.36 / $123.36 / $123.36
| Professional | | $123.36 | $123.36 | $123.36 |