- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $128.82 / $199.53
| Professional | | $102.33 | $128.82 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.98 / $194.98 / $501.19
| Facility | | $194.98 | $194.98 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $467.74 / $1,348.96
| Professional | | $147.91 | $467.74 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $186.21 / $446.68
| Professional | | $100.00 | $186.21 | $446.68 |