- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.21 / $124.21 / $143.32
| Professional | | $124.21 | $124.21 | $143.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.29 / $119.29 / $187.09
| Facility | | $119.29 | $119.29 | $187.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.08 / $87.08 / $118.67
| Professional | | $87.08 | $87.08 | $118.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.29 / $119.29 / $187.09
| Facility | | $119.29 | $119.29 | $187.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.08 / $87.08 / $118.67
| Professional | | $87.08 | $87.08 | $118.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.48 / $145.74 / $294.26
| Professional | | $86.48 | $145.74 | $294.26 |