- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $114.82 / $120.23
| Professional | | $97.72 | $114.82 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $269.15
| Professional | | $120.23 | $120.23 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $120.23 / $275.42
| Professional | | $52.48 | $120.23 | $275.42 |