- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $180.30
| Professional | | $104.73 | $104.73 | $180.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.56 / $118.56 / $118.56
| Facility | | $118.56 | $118.56 | $118.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.80 / $113.77 / $189.62
| Facility | | $98.80 | $113.77 | $189.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $104.73
| Professional | | $104.73 | $104.73 | $104.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.80 / $113.77 / $189.62
| Facility | | $98.80 | $113.77 | $189.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $104.73
| Professional | | $104.73 | $104.73 | $104.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.49 / $104.73 / $161.11
| Professional | | $99.49 | $104.73 | $161.11 |