- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.21 / $110.21 / $127.16
| Professional | | $110.21 | $110.21 | $127.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.12 / $141.12 / $165.99
| Facility | | $141.12 | $141.12 | $165.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.02 / $103.02 / $140.77
| Professional | | $103.02 | $103.02 | $140.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.12 / $141.12 / $165.99
| Facility | | $141.12 | $141.12 | $165.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.02 / $103.02 / $140.77
| Professional | | $103.02 | $103.02 | $140.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.50 / $150.50 / $150.50
| Facility | | $150.50 | $150.50 | $150.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.11 / $142.94 / $261.08
| Professional | | $75.11 | $142.94 | $261.08 |