- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.61 / $158.61 / $183.01
| Professional | | $158.61 | $158.61 | $183.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.21 / $159.21 / $159.21
| Facility | | $159.21 | $159.21 | $159.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.22 / $116.22 / $169.72
| Professional | | $116.22 | $116.22 | $169.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.21 / $159.21 / $159.21
| Facility | | $159.21 | $159.21 | $159.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.22 / $159.21 / $169.72
| Professional | | $116.22 | $159.21 | $169.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.10 / $192.53 / $375.73
| Professional | | $108.10 | $192.53 | $375.73 |