- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.50 / $105.26 / $105.26
| Professional | | $90.50 | $105.26 | $105.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.22 / $199.82 / $370.40
| Facility | | $154.22 | $199.82 | $370.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.61 / $110.66 / $110.66
| Professional | | $105.61 | $110.66 | $110.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.57 / $144.01 / $144.01
| Facility | | $121.57 | $144.01 | $144.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.13 / $105.13 / $144.01
| Professional | | $105.13 | $105.13 | $144.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.40 / $140.40 / $140.40
| Professional | | $140.40 | $140.40 | $140.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.64 / $105.26 / $105.26
| Professional | | $97.64 | $105.26 | $105.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.66 / $93.32 / $198.95
| Professional | | $66.66 | $93.32 | $198.95 |