- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.37 / $101.37 / $101.37
| Facility | | $101.37 | $101.37 | $101.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.81 / $101.37 / $101.37
| Professional | | $47.81 | $101.37 | $101.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.00 / $124.62 / $145.85
| Professional | | $79.00 | $124.62 | $145.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.96 / $120.28 / $216.51
| Professional | | $103.96 | $120.28 | $216.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.74 / $101.37 / $101.37
| Professional | | $48.74 | $101.37 | $101.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.00 / $136.00 / $187.00
| Professional | | $136.00 | $136.00 | $187.00 |