- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.36 / $137.06 / $233.60
| Professional | | $123.36 | $137.06 | $233.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.66 / $139.66 / $139.66
| Facility | | $139.66 | $139.66 | $139.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.38 / $116.38 / $270.30
| Facility | | $116.38 | $116.38 | $270.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.36 / $123.36 / $123.36
| Professional | | $123.36 | $123.36 | $123.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.38 / $116.38 / $270.30
| Facility | | $116.38 | $116.38 | $270.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.36 / $123.36 / $123.36
| Professional | | $123.36 | $123.36 | $123.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.19 / $123.36 / $189.77
| Professional | | $117.19 | $123.36 | $189.77 |