- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.68 / $121.68 / $152.10
| Professional | | $121.68 | $121.68 | $152.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.66 / $145.66 / $145.66
| Facility | | $145.66 | $145.66 | $145.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.79 / $335.79 / $335.79
| Professional | | $335.79 | $335.79 | $335.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.38 / $109.74 / $139.85
| Facility | | $87.38 | $109.74 | $139.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.38 / $118.84 / $148.66
| Professional | | $87.38 | $118.84 | $148.66 |