- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.38 / $101.38 / $101.38
| Facility | | $101.38 | $101.38 | $101.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.87 / $101.38 / $111.58
| Professional | | $99.87 | $101.38 | $111.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.22 / $123.58 / $203.91
| Professional | | $111.22 | $123.58 | $203.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.91 / $263.06 / $443.13
| Professional | | $116.91 | $263.06 | $443.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.12 / $237.48 / $237.48
| Professional | | $107.12 | $237.48 | $237.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.15 / $222.54 / $307.74
| Professional | | $87.15 | $222.54 | $307.74 |