- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.83 / $134.83 / $209.41
| Professional | | $134.83 | $134.83 | $209.41 |
- 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 / $148.32
| Professional | | $148.32 | $148.32 | $148.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.76 / $134.83 / $192.81
| Facility | | $83.76 | $134.83 | $192.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.43 / $132.43 / $145.66
| Professional | | $132.43 | $132.43 | $145.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.48 / $174.48 / $178.45
| Professional | | $174.48 | $174.48 | $178.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.65 / $158.62 / $158.91
| Professional | | $149.65 | $158.62 | $158.91 |