- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $177.83
| Professional | | $138.04 | $138.04 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $2,454.71
| Facility | | $1,548.82 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $138.04
| Professional | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Facility | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $288.40
| Professional | | $177.83 | $177.83 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $144.54 / $151.36
| Facility | | $138.04 | $144.54 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $154.88 / $199.53
| Professional | | $138.04 | $154.88 | $199.53 |