- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.92 / $105.92 / $105.92
| Facility | | $105.92 | $105.92 | $105.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.92 / $105.92 / $123.03
| Professional | | $62.92 | $105.92 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.26 / $14.36 / $14.56
| Professional | | $11.26 | $14.36 | $14.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.47 / $16.14 / $32.22
| Professional | | $9.47 | $16.14 | $32.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.16 / $165.50 / $323.49
| Professional | | $111.16 | $165.50 | $323.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |