- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.77 / $102.77 / $102.77
| Facility | | $102.77 | $102.77 | $102.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.40 / $102.77 / $102.77
| Professional | | $101.40 | $102.77 | $102.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.01 / $209.77 / $248.11
| Professional | | $193.01 | $209.77 | $248.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.76 / $234.44 / $302.75
| Professional | | $144.76 | $234.44 | $302.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.77 / $130.47 / $308.31
| Facility | | $102.77 | $130.47 | $308.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.70 / $196.62 / $266.82
| Professional | | $108.70 | $196.62 | $266.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.18 / $188.53 / $266.82
| Professional | | $115.18 | $188.53 | $266.82 |