- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.49 / $102.94 / $102.94
| Facility | | $101.49 | $102.94 | $102.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.94 / $102.94 / $174.56
| Professional | | $102.94 | $102.94 | $174.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.53 / $580.72 / $781.26
| Facility | | $478.53 | $580.72 | $781.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.94 / $102.94 / $102.94
| Facility | | $102.94 | $102.94 | $102.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.94 / $102.94 / $102.94
| Professional | | $102.94 | $102.94 | $102.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.93 / $102.93 / $102.93
| Facility | | $102.93 | $102.93 | $102.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.10 / $102.94 / $102.94
| Professional | | $98.10 | $102.94 | $102.94 |