- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.24 / $146.54 / $386.65
| Facility | | $141.24 | $146.54 | $386.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.24 / $146.54 / $150.07
| Professional | | $141.24 | $146.54 | $150.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.76 / $151.59 / $151.59
| Facility | | $145.76 | $151.59 | $151.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.55 / $176.55 / $176.55
| Professional | | $176.55 | $176.55 | $176.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.80 / $136.80 / $160.00
| Professional | | $136.80 | $136.80 | $160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.71 / $149.71 / $149.71
| Professional | | $149.71 | $149.71 | $149.71 |