- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.63 / $141.63 / $161.86
| Facility | | $141.63 | $141.63 | $161.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $141.63 / $161.86
| Professional | | $134.88 | $141.63 | $161.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.34 / $124.34 / $124.34
| Professional | | $124.34 | $124.34 | $124.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $134.88
| Facility | | $134.88 | $134.88 | $134.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $134.88
| Professional | | $134.88 | $134.88 | $134.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.15 / $134.88 / $175.36
| Professional | | $128.15 | $134.88 | $175.36 |