- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.21 / $137.21 / $137.21
| Facility | | $137.21 | $137.21 | $137.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.56 / $144.78 / $180.96
| Professional | | $135.56 | $144.78 | $180.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.67 / $188.67 / $188.67
| Professional | | $188.67 | $188.67 | $188.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.56 / $155.05 / $272.23
| Facility | | $135.56 | $155.05 | $272.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.01 / $194.45 / $1,193.31
| Professional | | $138.01 | $194.45 | $1,193.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.01 / $181.64 / $234.23
| Professional | | $138.01 | $181.64 | $234.23 |