- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.09 / $105.09 / $105.09
| Facility | | $105.09 | $105.09 | $105.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.78 / $105.09 / $111.70
| Professional | | $72.78 | $105.09 | $111.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.10 / $124.86 / $206.01
| Professional | | $109.10 | $124.86 | $206.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.10 / $124.10 / $124.10
| Facility | | $124.10 | $124.10 | $124.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.42 / $96.42 / $96.42
| Professional | | $96.42 | $96.42 | $96.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.35 / $154.52 / $276.38
| Professional | | $131.35 | $154.52 | $276.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.09 / $105.09 / $111.70
| Professional | | $105.09 | $105.09 | $111.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.69 / $153.82 / $217.79
| Professional | | $108.69 | $153.82 | $217.79 |