- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.80 / $119.61 / $119.61
| Facility | | $108.80 | $119.61 | $119.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.80 / $119.61 / $119.61
| Professional | | $108.80 | $119.61 | $119.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.85 / $196.44 / $351.84
| Facility | | $125.85 | $196.44 | $351.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.67 / $106.67 / $122.20
| Professional | | $106.67 | $106.67 | $122.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.35 / $131.35 / $131.35
| Facility | | $131.35 | $131.35 | $131.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.35 / $131.35 / $131.35
| Professional | | $131.35 | $131.35 | $131.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.28 / $132.53 / $140.74
| Professional | | $117.28 | $132.53 | $140.74 |