- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.21 / $124.21 / $124.21
| Facility | | $124.21 | $124.21 | $124.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.40 / $125.42 / $162.58
| Professional | | $101.40 | $125.42 | $162.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.38 / $157.32 / $263.69
| Professional | | $126.38 | $157.32 | $263.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.38 / $126.38 / $263.69
| Professional | | $126.38 | $126.38 | $263.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.13 / $139.46 / $189.28
| Professional | | $126.13 | $139.46 | $189.28 |