- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $111.15
| Professional | | $111.15 | $111.15 | $111.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.86 / $376.33 / $627.21
| Facility | | $104.86 | $376.33 | $627.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $627.21
| Professional | | $111.15 | $111.15 | $627.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.86 / $376.33 / $627.21
| Facility | | $104.86 | $376.33 | $627.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $627.21
| Professional | | $111.15 | $111.15 | $627.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $333.45
| Professional | | $111.15 | $111.15 | $333.45 |