- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.72 / $100.72 / $120.86
| Facility | | $100.72 | $100.72 | $120.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $120.86
| Professional | | $101.72 | $101.72 | $120.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $101.72
| Professional | | $101.72 | $101.72 | $101.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.96 / $101.72 / $101.72
| Facility | | $95.96 | $101.72 | $101.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $101.72
| Professional | | $101.72 | $101.72 | $101.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $147.63
| Professional | | $101.72 | $101.72 | $147.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $249.49
| Professional | | $101.72 | $101.72 | $249.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.83 / $186.81 / $237.76
| Professional | | $169.83 | $186.81 | $237.76 |