- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.88 / $105.88 / $105.88
| Facility | | $105.88 | $105.88 | $105.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.70 / $101.33 / $105.88
| Professional | | $98.70 | $101.33 | $105.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.19 / $276.67 / $358.65
| Facility | | $137.19 | $276.67 | $358.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.21 / $147.75 / $253.28
| Professional | | $133.21 | $147.75 | $253.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.11 / $149.11 / $247.34
| Facility | | $149.11 | $149.11 | $247.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.85 / $149.11 / $1,006.90
| Professional | | $108.85 | $149.11 | $1,006.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.42 / $103.88 / $160.38
| Professional | | $78.42 | $103.88 | $160.38 |