- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.21 / $432.65 / $526.95
| Facility | | $139.21 | $432.65 | $526.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $139.21 / $140.60
| Professional | | $139.21 | $139.21 | $140.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.66 / $138.66 / $166.14
| Professional | | $138.66 | $138.66 | $166.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.33 / $131.33 / $139.21
| Facility | | $131.33 | $131.33 | $139.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $139.21 / $176.26
| Professional | | $139.21 | $139.21 | $176.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.33 / $128.90 / $145.01
| Professional | | $118.33 | $128.90 | $145.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $154.97 / $182.38
| Professional | | $139.21 | $154.97 | $182.38 |