- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.61 / $182.94 / $182.94
| Facility | | $145.61 | $182.94 | $182.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.61 / $145.61 / $148.31
| Professional | | $145.61 | $145.61 | $148.31 |
- 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
- $100.63 / $148.32 / $148.32
| Professional | | $100.63 | $148.32 | $148.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.90 / $150.69 / $566.78
| Facility | | $120.90 | $150.69 | $566.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.81 / $156.27 / $158.91
| Professional | | $125.81 | $156.27 | $158.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.81 / $156.27 / $158.91
| Professional | | $125.81 | $156.27 | $158.91 |