- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $147.91 / $151.36
| Professional | | $141.25 | $147.91 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $151.36 / $194.98
| Professional | | $125.89 | $151.36 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Facility | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $162.18 / $162.18
| Professional | | $125.89 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $173.78 / $204.17
| Professional | | $151.36 | $173.78 | $204.17 |