- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.75 / $102.75 / $838.44
| Facility | | $102.75 | $102.75 | $838.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.75 / $102.75 / $106.86
| Professional | | $102.75 | $102.75 | $106.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.60 / $109.60 / $109.60
| Professional | | $109.60 | $109.60 | $109.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $222.63 / $231.53 / $497.57
| Facility | | $222.63 | $231.53 | $497.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.44 / $174.92 / $1,067.78
| Professional | | $77.44 | $174.92 | $1,067.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.55 / $278.48 / $278.48
| Professional | | $157.55 | $278.48 | $278.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $82.20 / $217.83
| Professional | | $57.54 | $82.20 | $217.83 |