- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.83 / $134.83 / $148.31
| Professional | | $134.83 | $134.83 | $148.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $409.46 / $409.46 / $409.46
| Facility | | $409.46 | $409.46 | $409.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.08 / $135.08 / $135.08
| Professional | | $135.08 | $135.08 | $135.08 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $134.83 / $156.00 / $239.31
| Professional | | $134.83 | $156.00 | $239.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.83 / $134.83 / $155.05
| Professional | | $134.83 | $134.83 | $155.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.43 / $132.43 / $198.65
| Professional | | $132.43 | $132.43 | $198.65 |