- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.77 / $137.77 / $215.54
| Facility | | $137.77 | $137.77 | $215.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.28 / $137.77 / $162.08
| Professional | | $131.28 | $137.77 | $162.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.66 / $162.08 / $182.27
| Professional | | $129.66 | $162.08 | $182.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Facility | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Professional | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $240.44
| Professional | | $162.08 | $162.08 | $240.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.11 / $162.08 / $170.18
| Professional | | $149.11 | $162.08 | $170.18 |