- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.28 / $103.28 / $103.28
| Facility | | $103.28 | $103.28 | $103.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.03 / $110.81 / $138.60
| Professional | | $102.03 | $110.81 | $138.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.22 / $145.22 / $145.22
| Professional | | $145.22 | $145.22 | $145.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.03 / $116.47 / $204.78
| Facility | | $102.03 | $116.47 | $204.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.67 / $146.40 / $920.30
| Professional | | $105.67 | $146.40 | $920.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.67 / $139.08 / $179.34
| Professional | | $105.67 | $139.08 | $179.34 |