- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.58 / $163.85 / $291.92
| Facility | | $129.58 | $163.85 | $291.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $133.36 / $177.81
| Professional | | $129.47 | $133.36 | $177.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.14 / $215.45 / $411.68
| Facility | | $131.14 | $215.45 | $411.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $129.58
| Professional | | $129.47 | $129.47 | $129.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.15 / $129.47 / $129.47
| Facility | | $122.15 | $129.47 | $129.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $129.47
| Professional | | $129.47 | $129.47 | $129.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $140.62
| Professional | | $129.47 | $129.47 | $140.62 |