- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $303.82
| Professional | | $104.71 | $104.71 | $303.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.13 / $108.13 / $108.13
| Professional | | $108.13 | $108.13 | $108.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.69 / $97.76 / $216.26
| Professional | | $81.69 | $97.76 | $216.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.64 / $478.59 / $845.26
| Professional | | $290.64 | $478.59 | $845.26 |