- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.27 / $426.27 / $426.27
| Facility | | $426.27 | $426.27 | $426.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.16 / $132.46 / $136.40
| Professional | | $131.16 | $132.46 | $136.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.04 / $132.04 / $333.63
| Facility | | $132.04 | $132.04 | $333.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.16 / $131.16 / $131.16
| Professional | | $131.16 | $131.16 | $131.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.73 / $131.16 / $131.16
| Facility | | $123.73 | $131.16 | $131.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.16 / $131.16 / $131.16
| Professional | | $131.16 | $131.16 | $131.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.16 / $131.16 / $146.01
| Professional | | $131.16 | $131.16 | $146.01 |