- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.17 / $117.17 / $205.19
| Professional | | $117.17 | $117.17 | $205.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.84 / $228.84 / $228.84
| Facility | | $228.84 | $228.84 | $228.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.84 / $228.84 / $228.84
| Professional | | $228.84 | $228.84 | $228.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.58 / $175.58 / $251.74
| Facility | | $175.58 | $175.58 | $251.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.16 / $128.16 / $175.58
| Professional | | $128.16 | $128.16 | $175.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.01 / $138.69 / $160.29
| Professional | | $94.01 | $138.69 | $160.29 |