- 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
- $104.71 / $109.65 / $112.20
| Professional | | $104.71 | $109.65 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $223.87 / $446.68
| Facility | | $123.03 | $223.87 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Professional | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.10 / $97.72 / $239.88
| Facility | | $87.10 | $97.72 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $104.71 / $117.49
| Professional | | $87.10 | $104.71 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Professional | | $112.20 | $112.20 | $112.20 |