- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.66 / $202.28 / $393.94
| Facility | | $136.66 | $202.28 | $393.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $137.59 / $165.11
| Professional | | $136.66 | $137.59 | $165.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.66 / $220.40 / $434.54
| Facility | | $136.66 | $220.40 | $434.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $136.66 / $157.62
| Professional | | $136.66 | $136.66 | $157.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.93 / $136.66 / $136.66
| Facility | | $128.93 | $136.66 | $136.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $136.66 / $141.82
| Professional | | $136.66 | $136.66 | $141.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $136.66 / $158.97
| Professional | | $136.66 | $136.66 | $158.97 |