- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.36 / $117.36 / $201.33
| Professional | | $117.36 | $117.36 | $201.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.86 / $132.86 / $132.86
| Facility | | $132.86 | $132.86 | $132.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.72 / $131.85 / $219.76
| Facility | | $110.72 | $131.85 | $219.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.36 / $117.36 / $117.36
| Professional | | $117.36 | $117.36 | $117.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.72 / $131.85 / $219.76
| Facility | | $110.72 | $131.85 | $219.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.36 / $117.36 / $117.36
| Professional | | $117.36 | $117.36 | $117.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.49 / $117.36 / $180.54
| Professional | | $111.49 | $117.36 | $180.54 |