- 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
- $318.33 / $318.33 / $318.33
| Professional | | $318.33 | $318.33 | $318.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.24 / $103.24 / $109.44
| Facility | | $103.24 | $103.24 | $109.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $139.38
| Professional | | $109.44 | $109.44 | $139.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.02 / $93.02 / $1,501.44
| Professional | | $93.02 | $93.02 | $1,501.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $177.38
| Professional | | $109.44 | $109.44 | $177.38 |