- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.72 / $101.98 / $136.58
| Professional | | $79.72 | $101.98 | $136.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.30 / $120.30 / $120.30
| Facility | | $120.30 | $120.30 | $120.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.26 / $120.30 / $123.91
| Professional | | $102.26 | $120.30 | $123.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.30 / $120.30 / $120.30
| Facility | | $120.30 | $120.30 | $120.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.30 / $120.30 / $123.91
| Professional | | $120.30 | $120.30 | $123.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.78 / $161.90 / $176.87
| Professional | | $62.78 | $161.90 | $176.87 |