- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.82 / $144.82 / $165.51
| Facility | | $144.82 | $144.82 | $165.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $144.82 / $165.51
| Professional | | $137.93 | $144.82 | $165.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.32 / $5.32 / $5.32
| Professional | | $5.32 | $5.32 | $5.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Facility | | $137.93 | $137.93 | $137.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Professional | | $137.93 | $137.93 | $137.93 |
- 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
- $124.14 / $137.93 / $179.31
| Professional | | $124.14 | $137.93 | $179.31 |