- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.08 / $131.78 / $131.78
| Professional | | $94.08 | $131.78 | $131.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.77 / $153.77 / $153.77
| Facility | | $153.77 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.69 / $153.77 / $153.77
| Professional | | $130.69 | $153.77 | $153.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.77 / $153.77 / $153.77
| Facility | | $153.77 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.77 / $153.77 / $153.77
| Professional | | $153.77 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.86 / $134.62 / $177.16
| Professional | | $70.86 | $134.62 | $177.16 |