- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.28 / $105.41 / $189.44
| Facility | | $87.28 | $105.41 | $189.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.28 / $87.98 / $105.20
| Professional | | $87.28 | $87.98 | $105.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.28 / $140.52 / $276.58
| Facility | | $87.28 | $140.52 | $276.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.28 / $87.28 / $87.28
| Professional | | $87.28 | $87.28 | $87.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82.34 / $87.28 / $87.28
| Facility | | $82.34 | $87.28 | $87.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.28 / $87.28 / $87.28
| Professional | | $87.28 | $87.28 | $87.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.28 / $87.28 / $96.01
| Professional | | $87.28 | $87.28 | $96.01 |