- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.21 / $123.21 / $123.21
| Facility | | $123.21 | $123.21 | $123.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.50 / $106.38 / $149.63
| Professional | | $90.50 | $106.38 | $149.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.48 / $157.34 / $241.41
| Professional | | $121.48 | $157.34 | $241.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.44 / $93.51 / $113.84
| Professional | | $71.44 | $93.51 | $113.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.64 / $241.34 / $381.86
| Professional | | $171.64 | $241.34 | $381.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.36 / $141.96 / $202.22
| Professional | | $103.36 | $141.96 | $202.22 |