- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.44 / $110.53 / $123.66
| Facility | | $109.44 | $110.53 | $123.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $120.38
| Professional | | $109.44 | $109.44 | $120.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.58 / $150.97 / $255.44
| Facility | | $125.58 | $150.97 | $255.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $164.16
| Professional | | $109.44 | $109.44 | $164.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.34 / $109.44 / $109.44
| Facility | | $106.34 | $109.44 | $109.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $118.73
| Professional | | $109.44 | $109.44 | $118.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $131.33
| Professional | | $109.44 | $109.44 | $131.33 |