- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.54 / $103.54 / $232.96
| Facility | | $103.54 | $103.54 | $232.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.54 / $129.41 / $129.41
| Professional | | $103.54 | $129.41 | $129.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.50 / $115.50 / $144.38
| Professional | | $115.50 | $115.50 | $144.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.54 / $147.50 / $310.62
| Facility | | $103.54 | $147.50 | $310.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.41 / $129.41 / $140.56
| Professional | | $129.41 | $129.41 | $140.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.01 / $129.41 / $140.56
| Professional | | $110.01 | $129.41 | $140.56 |