- 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
- $91.20 / $107.15 / $263.03
| Professional | | $91.20 | $107.15 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $416.87 / $416.87
| Professional | | $269.15 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $354.81
| Professional | | $173.78 | $173.78 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Facility | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $186.21 / $371.54
| Professional | | $109.65 | $186.21 | $371.54 |