- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.31 / $158.33 / $305.16
| Facility | | $143.31 | $158.33 | $305.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.41 / $139.94 / $143.31
| Professional | | $137.41 | $139.94 | $143.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.15 / $235.34 / $434.41
| Facility | | $153.15 | $235.34 | $434.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.50 / $140.50 / $143.31
| Professional | | $140.50 | $140.50 | $143.31 |
- 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
- $143.31 / $143.31 / $143.31
| Professional | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.50 / $140.50 / $157.36
| Professional | | $140.50 | $140.50 | $157.36 |