- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.33 / $167.46 / $314.40
| Facility | | $113.33 | $167.46 | $314.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $119.16 / $285.20
| Professional | | $114.54 | $119.16 | $285.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.54 / $190.59 / $366.53
| Facility | | $114.54 | $190.59 | $366.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $114.54 / $116.83
| Professional | | $114.54 | $114.54 | $116.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.05 / $114.54 / $114.54
| Facility | | $108.05 | $114.54 | $114.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $114.54 / $114.54
| Professional | | $114.54 | $114.54 | $114.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $114.54 / $153.13
| Professional | | $114.54 | $114.54 | $153.13 |