- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.54 / $105.54 / $121.78
| Professional | | $105.54 | $105.54 | $121.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.96 / $166.47 / $166.47
| Facility | | $158.96 | $166.47 | $166.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.52 / $166.47 / $177.47
| Professional | | $121.52 | $166.47 | $177.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.96 / $166.47 / $166.47
| Facility | | $158.96 | $166.47 | $166.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.52 / $166.47 / $177.47
| Professional | | $121.52 | $166.47 | $177.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.94 / $158.91 / $250.02
| Professional | | $71.94 | $158.91 | $250.02 |