- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.26 / $130.26 / $130.26
| Facility | | $130.26 | $130.26 | $130.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $121.16 / $122.27
| Professional | | $111.15 | $121.16 | $122.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.90 / $474.00 / $474.00
| Professional | | $402.90 | $474.00 | $474.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.86 / $104.86 / $104.86
| Facility | | $104.86 | $104.86 | $104.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $157.29 / $157.29
| Professional | | $111.15 | $157.29 | $157.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $111.15
| Professional | | $111.15 | $111.15 | $111.15 |