- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.32 / $113.44 / $126.48
| Facility | | $112.32 | $113.44 | $126.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $112.32 / $123.55
| Professional | | $112.32 | $112.32 | $123.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.13 / $150.18 / $254.09
| Facility | | $126.13 | $150.18 | $254.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $112.32 / $159.49
| Professional | | $112.32 | $112.32 | $159.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.14 / $112.32 / $112.32
| Facility | | $109.14 | $112.32 | $112.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $112.32 / $121.85
| Professional | | $112.32 | $112.32 | $121.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $112.32 / $129.16
| Professional | | $112.32 | $112.32 | $129.16 |