- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.36 / $101.36 / $101.36
| Facility | | $101.36 | $101.36 | $101.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.14 / $84.14 / $101.36
| Professional | | $84.14 | $84.14 | $101.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.32 / $141.97 / $144.43
| Professional | | $121.32 | $141.97 | $144.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.75 / $149.22 / $187.64
| Professional | | $147.75 | $149.22 | $187.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.14 / $146.03 / $585.33
| Facility | | $84.14 | $146.03 | $585.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.92 / $98.53 / $145.44
| Professional | | $57.92 | $98.53 | $145.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.60 / $96.39 / $145.44
| Professional | | $42.60 | $96.39 | $145.44 |