- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.29 / $101.29 / $101.29
| Facility | | $101.29 | $101.29 | $101.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.29 / $101.29 / $101.29
| Professional | | $101.29 | $101.29 | $101.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.08 / $106.08 / $106.08
| Professional | | $106.08 | $106.08 | $106.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.58 / $57.58 / $57.58
| Professional | | $57.58 | $57.58 | $57.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.51 / $123.51 / $377.21
| Professional | | $123.51 | $123.51 | $377.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.20 / $94.80 / $134.30
| Professional | | $63.20 | $94.80 | $134.30 |