- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.55 / $138.85 / $173.56
| Professional | | $113.55 | $138.85 | $173.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.16 / $97.38 / $133.88
| Facility | | $78.16 | $97.38 | $133.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.05 / $303.05 / $303.05
| Professional | | $303.05 | $303.05 | $303.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.00 / $121.58 / $121.58
| Facility | | $103.00 | $121.58 | $121.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $121.58 / $133.06
| Professional | | $75.00 | $121.58 | $133.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.41 / $102.78 / $107.63
| Professional | | $75.41 | $102.78 | $107.63 |