- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.11 / $101.11 / $116.67
| Professional | | $101.11 | $101.11 | $116.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.05 / $147.05 / $152.29
| Facility | | $147.05 | $147.05 | $152.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.35 / $107.35 / $116.75
| Professional | | $107.35 | $107.35 | $116.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.05 / $147.05 / $152.29
| Facility | | $147.05 | $147.05 | $152.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.35 / $107.35 / $116.75
| Professional | | $107.35 | $107.35 | $116.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.67 / $122.74 / $239.55
| Professional | | $71.67 | $122.74 | $239.55 |