- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.86 / $118.86 / $118.86
| Facility | | $118.86 | $118.86 | $118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.47 / $118.86 / $118.86
| Professional | | $109.47 | $118.86 | $118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.87 / $223.99 / $1,119.73
| Professional | | $161.87 | $223.99 | $1,119.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.16 / $1,373.27 / $1,374.36
| Facility | | $1,052.16 | $1,373.27 | $1,374.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.89 / $401.32 / $604.67
| Professional | | $112.89 | $401.32 | $604.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.05 / $294.36 / $294.36
| Professional | | $134.05 | $294.36 | $294.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.40 / $164.92 / $440.33
| Professional | | $141.40 | $164.92 | $440.33 |