- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.83 / $182.02 / $410.86
| Facility | | $134.83 | $182.02 | $410.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.83 / $134.83 / $182.02
| Professional | | $134.83 | $134.83 | $182.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.09 / $177.29 / $238.52
| Facility | | $146.09 | $177.29 | $238.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.43 / $132.43 / $132.43
| Professional | | $132.43 | $132.43 | $132.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.32 / $148.32 / $148.32
| Facility | | $148.32 | $148.32 | $148.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.32 / $148.32 / $157.91
| Professional | | $148.32 | $148.32 | $157.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.43 / $149.65 / $158.62
| Professional | | $132.43 | $149.65 | $158.62 |