- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.31 / $215.24 / $471.15
| Facility | | $143.31 | $215.24 | $471.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Professional | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.65 / $235.34 / $458.28
| Facility | | $159.65 | $235.34 | $458.28 |
- 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
- $143.31 / $143.31 / $143.31
| Professional | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.45 / $140.50 / $155.96
| Professional | | $126.45 | $140.50 | $155.96 |