- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.60 / $108.60 / $130.32
| Facility | | $108.60 | $108.60 | $130.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.32 / $137.93 / $151.72
| Professional | | $130.32 | $137.93 | $151.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Professional | | $137.93 | $137.93 | $137.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.12 / $137.93 / $137.93
| Facility | | $130.12 | $137.93 | $137.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Professional | | $137.93 | $137.93 | $137.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $200.19
| Professional | | $137.93 | $137.93 | $200.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $331.03
| Professional | | $137.93 | $137.93 | $331.03 |