- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.20 / $105.20 / $105.20
| Facility | | $105.20 | $105.20 | $105.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.40 / $100.68 / $105.20
| Professional | | $93.40 | $100.68 | $105.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.35 / $259.43 / $356.34
| Facility | | $132.35 | $259.43 | $356.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.35 / $142.53 / $230.60
| Professional | | $132.35 | $142.53 | $230.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.31 / $124.31 / $243.21
| Facility | | $124.31 | $124.31 | $243.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.75 / $90.75 / $1,019.38
| Professional | | $90.75 | $90.75 | $1,019.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.36 / $106.44 / $169.31
| Professional | | $80.36 | $106.44 | $169.31 |