- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $296.20
| Professional | | $101.72 | $101.72 | $296.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.96 / $115.68 / $192.80
| Facility | | $95.96 | $115.68 | $192.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $192.80
| Professional | | $101.72 | $101.72 | $192.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.96 / $115.68 / $192.80
| Facility | | $95.96 | $115.68 | $192.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $192.80
| Professional | | $101.72 | $101.72 | $192.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $305.16
| Professional | | $101.72 | $101.72 | $305.16 |