- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.53 / $115.53 / $115.53
| Facility | | $115.53 | $115.53 | $115.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.04 / $115.53 / $115.53
| Professional | | $108.04 | $115.53 | $115.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.91 / $100.91 / $106.97
| Facility | | $100.91 | $100.91 | $106.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $106.97
| Professional | | $106.97 | $106.97 | $106.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.93 / $73.43 / $155.11
| Facility | | $69.93 | $73.43 | $155.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.86 / $64.75 / $252.11
| Professional | | $37.86 | $64.75 | $252.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $131.15
| Professional | | $106.97 | $106.97 | $131.15 |