- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.54 / $103.54 / $129.41
| Facility | | $103.54 | $103.54 | $129.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.54 / $103.54 / $129.41
| Professional | | $103.54 | $103.54 | $129.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.91 / $154.01 / $178.56
| Facility | | $130.91 | $154.01 | $178.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.41 / $129.41 / $129.41
| Professional | | $129.41 | $129.41 | $129.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $88.54 / $129.41 / $195.36
| Facility | | $88.54 | $129.41 | $195.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.41 / $129.41 / $129.41
| Professional | | $129.41 | $129.41 | $129.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.41 / $129.41 / $134.65
| Professional | | $129.41 | $129.41 | $134.65 |