- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.74 / $103.74 / $103.74
| Facility | | $103.74 | $103.74 | $103.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.74 / $103.74 / $103.74
| Professional | | $103.74 | $103.74 | $103.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.50 / $141.50 / $173.26
| Professional | | $141.50 | $141.50 | $173.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.64 / $122.64 / $122.64
| Professional | | $122.64 | $122.64 | $122.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.75 / $164.75 / $503.13
| Professional | | $164.75 | $164.75 | $503.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.30 / $114.17 / $189.99
| Professional | | $84.30 | $114.17 | $189.99 |