- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.70 / $114.54 / $114.54
| Facility | | $97.70 | $114.54 | $114.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $115.68 / $127.24
| Professional | | $114.54 | $115.68 | $127.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.41 / $257.77 / $346.78
| Facility | | $212.41 | $257.77 | $346.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $114.54 / $114.54
| Professional | | $114.54 | $114.54 | $114.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.54 / $114.54 / $114.54
| Facility | | $114.54 | $114.54 | $114.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $114.54 / $266.07
| Professional | | $114.54 | $114.54 | $266.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $114.54 / $114.54
| Professional | | $114.54 | $114.54 | $114.54 |