- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.57 / $124.93 / $701.55
| Professional | | $113.57 | $124.93 | $701.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.91 / $146.91 / $440.97
| Facility | | $146.91 | $146.91 | $440.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.45 / $112.45 / $146.91
| Professional | | $112.45 | $112.45 | $146.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.91 / $146.91 / $440.97
| Facility | | $146.91 | $146.91 | $440.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.45 / $122.00 / $159.13
| Professional | | $112.45 | $122.00 | $159.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.45 / $112.45 / $112.45
| Professional | | $112.45 | $112.45 | $112.45 |