- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.14 / $104.67 / $109.24
| Facility | | $86.14 | $104.67 | $109.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.18 / $104.67 / $163.13
| Professional | | $92.18 | $104.67 | $163.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.07 / $115.07 / $115.07
| Professional | | $115.07 | $115.07 | $115.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82.87 / $91.86 / $116.50
| Facility | | $82.87 | $91.86 | $116.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.74 / $121.23 / $123.29
| Professional | | $102.74 | $121.23 | $123.29 |