- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.03 / $102.03 / $102.03
| Facility | | $102.03 | $102.03 | $102.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.79 / $111.92 / $150.93
| Professional | | $100.79 | $111.92 | $150.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.09 / $211.62 / $227.55
| Facility | | $150.09 | $211.62 | $227.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.86 / $125.57 / $181.01
| Professional | | $107.86 | $125.57 | $181.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.62 / $107.13 / $225.52
| Facility | | $56.62 | $107.13 | $225.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.42 / $149.49 / $854.73
| Professional | | $123.42 | $149.49 | $854.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.29 / $146.15 / $195.72
| Professional | | $123.29 | $146.15 | $195.72 |