- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.16 / $110.16 / $110.16
| Facility | | $110.16 | $110.16 | $110.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.45 / $110.16 / $113.25
| Professional | | $103.45 | $110.16 | $113.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.47 / $139.47 / $230.13
| Professional | | $139.47 | $139.47 | $230.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.26 / $146.22 / $352.98
| Professional | | $99.26 | $146.22 | $352.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.56 / $263.98 / $265.47
| Professional | | $122.56 | $263.98 | $265.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.07 / $136.50 / $407.42
| Professional | | $103.07 | $136.50 | $407.42 |