- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.63 / $149.76 / $460.13
| Facility | | $142.63 | $149.76 | $460.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.62 / $142.63 / $142.63
| Professional | | $142.62 | $142.63 | $142.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.63 / $142.63 / $142.63
| Facility | | $142.63 | $142.63 | $142.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.63 / $142.63 / $142.63
| Professional | | $142.63 | $142.63 | $142.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.63 / $142.63 / $142.63
| Facility | | $142.63 | $142.63 | $142.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.02 / $121.59 / $264.11
| Professional | | $65.02 | $121.59 | $264.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.58 / $141.47 / $299.52
| Professional | | $85.58 | $141.47 | $299.52 |