- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.54 / $103.54 / $103.54
| Facility | | $103.54 | $103.54 | $103.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.54 / $103.54 / $103.54
| Professional | | $103.54 | $103.54 | $103.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.84 / $111.84 / $129.41
| Professional | | $111.84 | $111.84 | $129.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.66 / $116.66 / $116.66
| Professional | | $116.66 | $116.66 | $116.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.54 / $195.36 / $3,450.15
| Facility | | $103.54 | $195.36 | $3,450.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.01 / $129.41 / $130.71
| Professional | | $110.01 | $129.41 | $130.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.01 / $129.41 / $137.30
| Professional | | $110.01 | $129.41 | $137.30 |