- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $141.25 / $141.25
| Facility | | $131.83 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $66.07
| Professional | | $56.23 | $56.23 | $66.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $64.57 / $177.83
| Facility | | $54.95 | $64.57 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $58.88
| Professional | | $56.23 | $56.23 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $81.28
| Facility | | $56.23 | $56.23 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $56.23
| Professional | | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $56.23
| Professional | | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $131.83 / $141.25
| Facility | | $131.83 | $131.83 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $57.54 / $87.10
| Professional | | $56.23 | $57.54 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $67.61
| Professional | | $56.23 | $56.23 | $67.61 |