- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.61 / $103.61 / $103.61
| Facility | | $103.61 | $103.61 | $103.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.61 / $103.61 / $103.61
| Professional | | $103.61 | $103.61 | $103.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.51 / $108.93 / $132.87
| Professional | | $108.51 | $108.93 | $132.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.05 / $88.05 / $88.05
| Professional | | $88.05 | $88.05 | $88.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.35 / $126.35 / $385.85
| Professional | | $126.35 | $126.35 | $385.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.65 / $96.97 / $165.74
| Professional | | $64.65 | $96.97 | $165.74 |