- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.66 / $97.66 / $97.66
| Facility | | $97.66 | $97.66 | $97.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.37 / $96.90 / $110.48
| Professional | | $82.37 | $96.90 | $110.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.26 / $153.47 / $209.52
| Professional | | $120.26 | $153.47 | $209.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.71 / $131.57 / $232.65
| Professional | | $101.71 | $131.57 | $232.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.71 / $141.69 / $243.65
| Professional | | $101.71 | $141.69 | $243.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.46 / $136.46 / $349.20
| Professional | | $108.46 | $136.46 | $349.20 |