- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.87 / $101.51 / $130.44
| Professional | | $90.87 | $101.51 | $130.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.63 / $141.63 / $141.63
| Facility | | $141.63 | $141.63 | $141.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.63 / $141.63 / $141.63
| Professional | | $141.63 | $141.63 | $141.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.50 / $111.50 / $163.72
| Facility | | $111.50 | $111.50 | $163.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.78 / $111.50 / $129.57
| Professional | | $94.78 | $111.50 | $129.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.48 / $83.28 / $172.53
| Professional | | $53.48 | $83.28 | $172.53 |