- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.16 / $105.16 / $105.16
| Facility | | $105.16 | $105.16 | $105.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.38 / $105.16 / $174.94
| Professional | | $98.38 | $105.16 | $174.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.98 / $603.98 / $630.35
| Facility | | $603.98 | $603.98 | $630.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.22 / $191.64 / $235.30
| Professional | | $142.22 | $191.64 | $235.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.80 / $235.30 / $235.30
| Professional | | $189.80 | $235.30 | $235.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.11 / $269.55 / $354.34
| Professional | | $134.11 | $269.55 | $354.34 |