- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.32 / $124.32 / $217.71
| Professional | | $124.32 | $124.32 | $217.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.80 / $242.80 / $242.80
| Facility | | $242.80 | $242.80 | $242.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.80 / $242.80 / $242.80
| Professional | | $242.80 | $242.80 | $242.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.47 / $166.47 / $261.22
| Facility | | $166.47 | $166.47 | $261.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.52 / $121.52 / $166.47
| Professional | | $121.52 | $121.52 | $166.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.32 / $105.47 / $162.52
| Professional | | $95.32 | $105.47 | $162.52 |