- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.35 / $109.82 / $1,253.19
| Facility | | $108.35 | $109.82 | $1,253.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.53 / $108.36 / $108.36
| Professional | | $104.53 | $108.36 | $108.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Facility | | $108.36 | $108.36 | $108.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Professional | | $108.36 | $108.36 | $108.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.24 / $106.24 / $127.49
| Professional | | $106.24 | $106.24 | $127.49 |