- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $136.66 / $234.04
| Professional | | $136.66 | $136.66 | $234.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.72 / $154.72 / $154.72
| Facility | | $154.72 | $154.72 | $154.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.93 / $150.25 / $250.42
| Facility | | $128.93 | $150.25 | $250.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $136.66 / $250.42
| Professional | | $136.66 | $136.66 | $250.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.93 / $150.25 / $250.42
| Facility | | $128.93 | $150.25 | $250.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $136.66 / $250.42
| Professional | | $136.66 | $136.66 | $250.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.38 / $142.13 / $315.76
| Professional | | $113.38 | $142.13 | $315.76 |