- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.83 / $229.53 / $229.53
| Facility | | $134.83 | $229.53 | $229.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.83 / $134.83 / $134.83
| Professional | | $134.83 | $134.83 | $134.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.01 / $142.86 / $144.91
| Professional | | $121.01 | $142.86 | $144.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.38 / $127.64 / $157.97
| Professional | | $126.38 | $127.64 | $157.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.02 / $134.83 / $404.49
| Facility | | $114.02 | $134.83 | $404.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.83 / $145.66 / $158.62
| Professional | | $143.83 | $145.66 | $158.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.43 / $145.66 / $149.65
| Professional | | $132.43 | $145.66 | $149.65 |