- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.16 / $107.97 / $142.33
| Professional | | $98.16 | $107.97 | $142.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.46 / $105.46 / $188.96
| Facility | | $105.46 | $105.46 | $188.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.46 / $105.46 / $175.77
| Facility | | $105.46 | $105.46 | $175.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.58 / $96.58 / $96.58
| Professional | | $96.58 | $96.58 | $96.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.46 / $105.46 / $175.77
| Facility | | $105.46 | $105.46 | $175.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.58 / $96.58 / $96.58
| Professional | | $96.58 | $96.58 | $96.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.25 / $103.33 / $158.94
| Professional | | $93.25 | $103.33 | $158.94 |