- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.57 / $136.57 / $271.77
| Facility | | $136.57 | $136.57 | $271.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.57 / $136.57 / $136.57
| Professional | | $136.57 | $136.57 | $136.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Facility | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.45 / $143.31 / $143.31
| Professional | | $99.45 | $143.31 | $143.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.57 / $168.60 / $632.25
| Facility | | $136.57 | $168.60 | $632.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.50 / $140.50 / $140.50
| Professional | | $140.50 | $140.50 | $140.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.50 / $140.50 / $140.50
| Professional | | $140.50 | $140.50 | $140.50 |