- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.89 / $128.82 / $4,570.88
| Facility | | $125.89 | $128.82 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $138.04 / $138.04
| Professional | | $125.89 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $41.69 / $125.89
| Professional | | $40.74 | $41.69 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $162.18 / $186.21
| Professional | | $154.88 | $162.18 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $190.55 / $213.80
| Professional | | $134.90 | $190.55 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $134.90 / $134.90
| Professional | | $123.03 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |