- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.22 / $148.22 / $171.03
| Professional | | $148.22 | $148.22 | $171.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.52 / $166.52 / $223.25
| Facility | | $166.52 | $166.52 | $223.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.56 / $166.52 / $177.52
| Professional | | $121.56 | $166.52 | $177.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.52 / $166.52 / $223.25
| Facility | | $166.52 | $166.52 | $223.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.56 / $166.52 / $177.52
| Professional | | $121.56 | $166.52 | $177.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.06 / $228.27 / $351.15
| Professional | | $105.06 | $228.27 | $351.15 |