- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.85 / $110.85 / $136.60
| Facility | | $110.85 | $110.85 | $136.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.52 / $113.64 / $172.75
| Professional | | $85.52 | $113.64 | $172.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.01 / $143.57 / $209.28
| Professional | | $82.01 | $143.57 | $209.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.81 / $113.33 / $144.65
| Professional | | $92.81 | $113.33 | $144.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.84 / $145.38 / $195.74
| Professional | | $106.84 | $145.38 | $195.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.60 / $126.36 / $193.14
| Professional | | $108.60 | $126.36 | $193.14 |