- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.84 / $132.38 / $201.64
| Facility | | $101.84 | $132.38 | $201.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.16 / $101.84 / $101.84
| Professional | | $98.16 | $101.84 | $101.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.39 / $108.39 / $108.39
| Facility | | $108.39 | $108.39 | $108.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.39 / $108.39 / $108.39
| Professional | | $108.39 | $108.39 | $108.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.70 / $541.95 / $541.95
| Facility | | $122.70 | $541.95 | $541.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.57 / $122.70 / $122.70
| Professional | | $116.57 | $122.70 | $122.70 |