- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.16 / $110.16 / $127.11
| Professional | | $110.16 | $110.16 | $127.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.91 / $170.15 / $170.15
| Facility | | $165.91 | $170.15 | $170.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.21 / $161.19 / $181.39
| Professional | | $124.21 | $161.19 | $181.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.91 / $170.15 / $170.15
| Facility | | $165.91 | $170.15 | $170.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.21 / $170.15 / $181.39
| Professional | | $124.21 | $170.15 | $181.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.08 / $153.44 / $260.97
| Professional | | $75.08 | $153.44 | $260.97 |