- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.75 / $101.75 / $117.41
| Professional | | $101.75 | $101.75 | $117.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.24 / $175.58 / $175.58
| Facility | | $153.24 | $175.58 | $175.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.16 / $175.58 / $187.18
| Professional | | $128.16 | $175.58 | $187.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.24 / $175.58 / $175.58
| Facility | | $153.24 | $175.58 | $175.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.16 / $175.58 / $187.18
| Professional | | $128.16 | $175.58 | $187.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.92 / $166.13 / $173.37
| Professional | | $93.92 | $166.13 | $173.37 |