- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.81 / $113.81 / $131.32
| Professional | | $113.81 | $113.81 | $131.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.51 / $135.51 / $171.41
| Facility | | $135.51 | $135.51 | $171.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.92 / $135.51 / $139.58
| Professional | | $98.92 | $135.51 | $139.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.51 / $135.51 / $171.41
| Facility | | $135.51 | $135.51 | $171.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.92 / $135.51 / $139.58
| Professional | | $98.92 | $135.51 | $139.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.23 / $175.27 / $193.91
| Professional | | $98.23 | $175.27 | $193.91 |