- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.72 / $101.72 / $176.26
| Facility | | $100.72 | $101.72 | $176.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $106.80
| Professional | | $101.72 | $101.72 | $106.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.71 / $104.51 / $270.57
| Professional | | $100.71 | $104.51 | $270.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $101.72
| Facility | | $101.72 | $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
- Facility
- Modifier
- Low / Median / High Price
- $229.98 / $515.16 / $515.16
| Facility | | $229.98 | $515.16 | $515.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.16 / $515.16 / $515.16
| Professional | | $515.16 | $515.16 | $515.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.63 / $101.72 / $101.72
| Professional | | $96.63 | $101.72 | $101.72 |