- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.92 / $132.30 / $150.76
| Professional | | $100.92 | $132.30 | $150.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.26 / $151.26 / $151.26
| Professional | | $151.26 | $151.26 | $151.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.41 / $166.76 / $166.76
| Professional | | $153.41 | $166.76 | $166.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.47 / $114.47 / $181.84
| Facility | | $114.47 | $114.47 | $181.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.30 / $114.47 / $202.50
| Professional | | $97.30 | $114.47 | $202.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.54 / $102.77 / $153.84
| Professional | | $61.54 | $102.77 | $153.84 |