- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.70 / $104.70 / $104.70
| Facility | | $104.70 | $104.70 | $104.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.52 / $104.70 / $104.70
| Professional | | $96.52 | $104.70 | $104.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.35 / $187.86 / $647.48
| Professional | | $140.35 | $187.86 | $647.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.16 / $1,080.20 / $1,081.04
| Facility | | $1,052.16 | $1,080.20 | $1,081.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.01 / $308.83 / $534.51
| Professional | | $99.01 | $308.83 | $534.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.57 / $258.88 / $258.88
| Professional | | $117.57 | $258.88 | $258.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.01 / $130.11 / $387.26
| Professional | | $122.01 | $130.11 | $387.26 |