- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.38 / $133.38 / $133.38
| Facility | | $133.38 | $133.38 | $133.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $116.71 / $133.38
| Professional | | $111.15 | $116.71 | $133.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.31 / $141.31 / $141.31
| Facility | | $141.31 | $141.31 | $141.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.31 / $141.31 / $141.31
| Professional | | $141.31 | $141.31 | $141.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.86 / $111.15 / $111.15
| Facility | | $104.86 | $111.15 | $111.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $120.59
| Professional | | $111.15 | $111.15 | $120.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.04 / $111.15 / $126.71
| Professional | | $100.04 | $111.15 | $126.71 |