- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.94 / $151.27 / $151.27
| Professional | | $145.94 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.73 / $77.05 / $77.05
| Professional | | $23.73 | $77.05 | $77.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.27 / $151.27 / $151.27
| Facility | | $151.27 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.27 / $151.27 / $151.27
| Professional | | $151.27 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.27 / $151.27 / $151.27
| Professional | | $151.27 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.79 / $161.79 / $283.13
| Professional | | $161.79 | $161.79 | $283.13 |