- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.04 / $96.21 / $150.44
| Professional | | $89.04 | $96.21 | $150.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.78 / $167.78 / $167.78
| Facility | | $167.78 | $167.78 | $167.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.78 / $167.78 / $167.78
| Professional | | $167.78 | $167.78 | $167.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.32 / $103.32 / $146.26
| Facility | | $103.32 | $103.32 | $146.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.42 / $75.42 / $103.32
| Professional | | $75.42 | $75.42 | $103.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.49 / $65.81 / $73.06
| Professional | | $59.49 | $65.81 | $73.06 |