- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.60 / $119.60 / $121.17
| Facility | | $119.60 | $119.60 | $121.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.80 / $104.58 / $121.17
| Professional | | $90.80 | $104.58 | $121.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.61 / $146.61 / $225.93
| Professional | | $124.61 | $146.61 | $225.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.61 / $93.51 / $116.28
| Professional | | $71.61 | $93.51 | $116.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.65 / $149.36 / $189.20
| Professional | | $116.65 | $149.36 | $189.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.45 / $129.13 / $176.40
| Professional | | $93.45 | $129.13 | $176.40 |