- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.23 / $95.39 / $127.76
| Professional | | $74.23 | $95.39 | $127.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.51 / $115.51 / $151.61
| Facility | | $115.51 | $115.51 | $151.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.18 / $115.51 / $151.61
| Professional | | $98.18 | $115.51 | $151.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.51 / $115.51 / $151.61
| Facility | | $115.51 | $115.51 | $151.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.51 / $115.51 / $151.61
| Professional | | $115.51 | $115.51 | $151.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.82 / $144.41 / $197.83
| Professional | | $57.82 | $144.41 | $197.83 |