- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $387.22
| Professional | | $101.03 | $101.03 | $387.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.31 / $119.39 / $198.99
| Facility | | $95.31 | $119.39 | $198.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $198.99
| Professional | | $101.03 | $101.03 | $198.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.31 / $119.39 / $198.99
| Facility | | $95.31 | $119.39 | $198.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $198.99
| Professional | | $101.03 | $101.03 | $198.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $303.08
| Professional | | $101.03 | $101.03 | $303.08 |