- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $141.25
| Professional | | $112.20 | $112.20 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $158.49
| Professional | | $151.36 | $151.36 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $72.44 / $204.17
| Facility | | $64.57 | $72.44 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $95.50 / $107.15
| Professional | | $52.48 | $95.50 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $52.48 / $52.48
| Professional | | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.48 / $52.48 / $52.48
| Facility | | $52.48 | $52.48 | $52.48 |