- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.66 / $330.74 / $517.66
| Facility | | $136.66 | $330.74 | $517.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $136.66 / $187.68
| Professional | | $136.66 | $136.66 | $187.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.22 / $136.22 / $163.22
| Professional | | $136.22 | $136.22 | $163.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.93 / $128.93 / $136.66
| Facility | | $128.93 | $128.93 | $136.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $136.66 / $171.74
| Professional | | $136.66 | $136.66 | $171.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.17 / $127.18 / $143.07
| Professional | | $116.17 | $127.18 | $143.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $152.13 / $201.18
| Professional | | $136.66 | $152.13 | $201.18 |