- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $263.03
| Professional | | $104.71 | $104.71 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.50 / $95.50 / $141.25
| Facility | | $95.50 | $95.50 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $107.15 / $141.25
| Professional | | $95.50 | $107.15 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.28 / $102.33 / $162.18
| Facility | | $81.28 | $102.33 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $102.33 / $162.18
| Professional | | $81.28 | $102.33 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.28 / $109.65 / $162.18
| Facility | | $81.28 | $109.65 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $104.71 / $141.25
| Professional | | $79.43 | $104.71 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.37 / $52.48 / $102.33
| Facility | | $5.37 | $52.48 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $66.07 / $77.62
| Professional | | $60.26 | $66.07 | $77.62 |