- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.61 / $119.61 / $119.61
| Facility | | $119.61 | $119.61 | $119.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.61 / $119.61 / $119.61
| Professional | | $119.61 | $119.61 | $119.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.17 / $126.52 / $128.34
| Professional | | $107.17 | $126.52 | $128.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.50 / $107.57 / $133.13
| Professional | | $106.50 | $107.57 | $133.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.55 / $108.80 / $326.39
| Facility | | $47.55 | $108.80 | $326.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.85 / $129.01 / $140.74
| Professional | | $115.85 | $129.01 | $140.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.24 / $129.01 / $132.53
| Professional | | $110.24 | $129.01 | $132.53 |