- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.11 / $169.92 / $169.92
| Facility | | $116.11 | $169.92 | $169.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.11 / $120.36 / $169.92
| Professional | | $116.11 | $120.36 | $169.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.60 / $111.60 / $122.76
| Facility | | $111.60 | $111.60 | $122.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.21 / $120.36 / $120.36
| Facility | | $116.21 | $120.36 | $120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Professional | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $17.00 / $20.00
| Professional | | $17.00 | $17.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.28 / $118.00 / $153.40
| Professional | | $113.28 | $118.00 | $153.40 |