- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $125.89
| Facility | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $117.49 / $134.90
| Professional | | $97.72 | $117.49 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $125.89 / $218.78
| Professional | | $97.72 | $125.89 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $186.21
| Professional | | $128.82 | $128.82 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $194.98 / $239.88
| Professional | | $194.98 | $194.98 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $134.90
| Professional | | $125.89 | $125.89 | $134.90 |