- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.36 / $142.91 / $726.82
| Facility | | $108.36 | $142.91 | $726.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Professional | | $108.36 | $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
- $132.60 / $273.72 / $273.72
| Professional | | $132.60 | $273.72 | $273.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.24 / $106.24 / $172.19
| Professional | | $106.24 | $106.24 | $172.19 |