- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.38 / $105.38 / $105.38
| Facility | | $105.38 | $105.38 | $105.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.33 / $105.38 / $105.38
| Professional | | $105.33 | $105.38 | $105.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.35 / $160.41 / $180.02
| Professional | | $132.35 | $160.41 | $180.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.48 / $92.39 / $116.18
| Professional | | $91.48 | $92.39 | $116.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.52 / $119.42 / $378.15
| Facility | | $56.52 | $119.42 | $378.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $79.61 / $154.63
| Professional | | $39.81 | $79.61 | $154.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.44 / $53.45 / $154.63
| Professional | | $33.44 | $53.45 | $154.63 |