- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.43 / $102.23 / $102.23
| Professional | | $95.43 | $102.23 | $102.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.22 / $147.22 / $147.22
| Facility | | $147.22 | $147.22 | $147.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.14 / $132.50 / $147.22
| Professional | | $125.14 | $132.50 | $147.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.01 / $60.51 / $94.47
| Facility | | $44.01 | $60.51 | $94.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.42 / $103.06 / $175.44
| Professional | | $50.42 | $103.06 | $175.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.71 / $147.53 / $164.13
| Professional | | $121.71 | $147.53 | $164.13 |