- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.72 / $132.65 / $137.50
| Professional | | $131.72 | $132.65 | $137.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.71 / $147.71 / $147.71
| Professional | | $147.71 | $147.71 | $147.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.65 / $222.61 / $265.30
| Facility | | $132.65 | $222.61 | $265.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.13 / $134.13 / $134.13
| Professional | | $134.13 | $134.13 | $134.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.71 / $147.71 / $147.71
| Facility | | $147.71 | $147.71 | $147.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.13 / $147.71 / $151.33
| Professional | | $134.13 | $147.71 | $151.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.00 / $180.00 / $180.00
| Professional | | $180.00 | $180.00 | $180.00 |