- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.66 / $141.66 / $163.47
| Professional | | $141.66 | $141.66 | $163.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.85 / $140.85 / $213.38
| Facility | | $140.85 | $140.85 | $213.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.82 / $102.82 / $135.49
| Professional | | $102.82 | $102.82 | $135.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.85 / $140.85 / $213.38
| Facility | | $140.85 | $140.85 | $213.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.82 / $102.82 / $135.49
| Professional | | $102.82 | $102.82 | $135.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.63 / $231.32 / $241.40
| Professional | | $108.63 | $231.32 | $241.40 |