- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $130.26
| Facility | | $111.15 | $111.15 | $130.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $114.49
| Professional | | $111.15 | $111.15 | $114.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.22 / $317.22 / $317.22
| Facility | | $317.22 | $317.22 | $317.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.22 / $317.22 / $317.22
| Professional | | $317.22 | $317.22 | $317.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.86 / $104.86 / $448.62
| Facility | | $104.86 | $104.86 | $448.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $111.15
| Professional | | $111.15 | $111.15 | $111.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.82 / $130.26 / $212.08
| Facility | | $117.82 | $130.26 | $212.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.16 / $122.27 / $157.83
| Professional | | $121.16 | $122.27 | $157.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $111.15
| Professional | | $111.15 | $111.15 | $111.15 |