- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.85 / $102.85 / $102.85
| Facility | | $102.85 | $102.85 | $102.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.66 / $101.35 / $102.85
| Professional | | $80.66 | $101.35 | $102.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.91 / $38.49 / $51.96
| Facility | | $31.91 | $38.49 | $51.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.12 / $93.31 / $110.11
| Professional | | $68.12 | $93.31 | $110.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.19 / $115.65 / $137.81
| Professional | | $77.19 | $115.65 | $137.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.78 / $87.70 / $129.58
| Professional | | $65.78 | $87.70 | $129.58 |