- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.81 / $113.81 / $211.69
| Facility | | $113.81 | $113.81 | $211.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $113.81 / $131.32
| Professional | | $109.44 | $113.81 | $131.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $109.44
| Professional | | $109.44 | $109.44 | $109.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $109.44
| Facility | | $109.44 | $109.44 | $109.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $109.44
| Professional | | $109.44 | $109.44 | $109.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $224.03
| Professional | | $109.44 | $109.44 | $224.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.97 / $109.44 / $116.01
| Professional | | $103.97 | $109.44 | $116.01 |