- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $123.03
| Facility | | $102.33 | $102.33 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $102.33 / $102.33
| Professional | | $83.18 | $102.33 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $213.80 / $371.54
| Facility | | $144.54 | $213.80 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $117.49
| Professional | | $102.33 | $102.33 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.75 / $11.75 / $11.75
| Professional | | $11.75 | $11.75 | $11.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $173.78 / $194.98
| Professional | | $102.33 | $173.78 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $158.49
| Professional | | $102.33 | $102.33 | $158.49 |