- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.51 / $142.51 / $142.51
| Facility | | $142.51 | $142.51 | $142.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.29 / $144.50 / $183.67
| Professional | | $124.29 | $144.50 | $183.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $141.06
| Professional | | $141.06 | $141.06 | $141.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.58 / $148.12 / $261.14
| Facility | | $140.58 | $148.12 | $261.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.59 / $198.00 / $1,105.55
| Professional | | $150.59 | $198.00 | $1,105.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.69 / $195.32 / $251.86
| Professional | | $148.69 | $195.32 | $251.86 |