- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $127.24 / $167.85
| Professional | | $114.54 | $127.24 | $167.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.66 / $129.66 / $129.66
| Facility | | $129.66 | $129.66 | $129.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.05 / $141.85 / $236.41
| Facility | | $108.05 | $141.85 | $236.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $114.54 / $114.54
| Professional | | $114.54 | $114.54 | $114.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.05 / $141.85 / $236.41
| Facility | | $108.05 | $141.85 | $236.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $114.54 / $114.54
| Professional | | $114.54 | $114.54 | $114.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.81 / $114.54 / $243.78
| Professional | | $108.81 | $114.54 | $243.78 |