- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.47 / $134.47 / $250.43
| Facility | | $134.47 | $134.47 | $250.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.62 / $134.47 / $137.72
| Professional | | $129.62 | $134.47 | $137.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.72 / $137.72 / $137.72
| Facility | | $137.72 | $137.72 | $137.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.72 / $137.72 / $137.72
| Professional | | $137.72 | $137.72 | $137.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.72 / $137.72 / $137.72
| Facility | | $137.72 | $137.72 | $137.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.04 / $324.04 / $324.04
| Professional | | $324.04 | $324.04 | $324.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.91 / $153.91 / $153.91
| Professional | | $153.91 | $153.91 | $153.91 |