- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.32 / $106.32 / $106.32
| Facility | | $106.32 | $106.32 | $106.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.65 / $80.65 / $106.32
| Professional | | $80.65 | $80.65 | $106.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.41 / $161.97 / $164.78
| Professional | | $138.41 | $161.97 | $164.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.50 / $156.05 / $196.22
| Professional | | $154.50 | $156.05 | $196.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.65 / $119.07 / $671.07
| Facility | | $80.65 | $119.07 | $671.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.48 / $77.67 / $125.07
| Professional | | $55.48 | $77.67 | $125.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.38 / $105.58 / $150.11
| Professional | | $44.38 | $105.58 | $150.11 |