- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.46 / $105.46 / $105.46
| Facility | | $105.46 | $105.46 | $105.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.96 / $105.46 / $109.41
| Professional | | $90.96 | $105.46 | $109.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.50 / $28.50 / $76.52
| Professional | | $28.50 | $28.50 | $76.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $112.05
| Facility | | $112.05 | $112.05 | $112.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $112.05
| Professional | | $112.05 | $112.05 | $112.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.46 / $105.46 / $177.17
| Facility | | $105.46 | $105.46 | $177.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.00 / $155.00 / $329.00
| Professional | | $155.00 | $155.00 | $329.00 |