- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.34 / $106.34 / $106.34
| Facility | | $106.34 | $106.34 | $106.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.36 / $86.36 / $106.34
| Professional | | $86.36 | $86.36 | $106.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.11 / $162.79 / $165.60
| Professional | | $139.11 | $162.79 | $165.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.88 / $168.54 / $211.93
| Professional | | $166.88 | $168.54 | $211.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.14 / $106.34 / $640.17
| Facility | | $71.14 | $106.34 | $640.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.23 / $72.31 / $116.46
| Professional | | $58.23 | $72.31 | $116.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.32 / $72.31 / $116.46
| Professional | | $41.32 | $72.31 | $116.46 |