- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.22 / $103.22 / $103.22
| Facility | | $103.22 | $103.22 | $103.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.22 / $103.22 / $103.22
| Professional | | $103.22 | $103.22 | $103.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.27 / $101.27 / $101.27
| Professional | | $101.27 | $101.27 | $101.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.11 / $34.11 / $34.11
| Professional | | $34.11 | $34.11 | $34.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.08 / $101.19 / $164.01
| Professional | | $92.08 | $101.19 | $164.01 |