- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.02 / $146.02 / $146.02
| Professional | | $146.02 | $146.02 | $146.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.51 / $145.51 / $168.70
| Professional | | $145.51 | $145.51 | $168.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.77 / $153.77 / $153.77
| Facility | | $153.77 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.44 / $153.77 / $153.77
| Professional | | $18.44 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.11 / $193.11 / $193.11
| Professional | | $193.11 | $193.11 | $193.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.08 / $94.08 / $146.02
| Professional | | $94.08 | $94.08 | $146.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.44 / $105.44 / $224.00
| Professional | | $70.44 | $105.44 | $224.00 |