- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.54 / $116.76 / $308.08
| Facility | | $112.54 | $116.76 | $308.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.54 / $116.76 / $119.58
| Professional | | $112.54 | $116.76 | $119.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.08 / $119.58 / $119.58
| Facility | | $113.08 | $119.58 | $119.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.58 / $119.58 / $119.58
| Professional | | $119.58 | $119.58 | $119.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.58 / $119.58 / $119.58
| Facility | | $119.58 | $119.58 | $119.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.58 / $119.58 / $119.58
| Professional | | $119.58 | $119.58 | $119.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.24 / $117.24 / $123.10
| Professional | | $117.24 | $117.24 | $123.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.86 / $110.86 / $130.16
| Professional | | $110.86 | $110.86 | $130.16 |