- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.46 / $105.46 / $105.46
| Facility | | $105.46 | $105.46 | $105.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.46 / $105.46 / $112.05
| Professional | | $105.46 | $105.46 | $112.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $112.05
| Facility | | $112.05 | $112.05 | $112.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $112.05
| Professional | | $112.05 | $112.05 | $112.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.00 / $200.00 / $345.40
| Professional | | $120.00 | $200.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |