- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.47 / $103.47 / $103.47
| Facility | | $103.47 | $103.47 | $103.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.87 / $98.09 / $361.52
| Professional | | $75.87 | $98.09 | $361.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.87 / $110.87 / $291.66
| Professional | | $110.87 | $110.87 | $291.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.56 / $106.91 / $225.10
| Professional | | $89.56 | $106.91 | $225.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.56 / $110.36 / $188.62
| Professional | | $89.56 | $110.36 | $188.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.32 / $134.19 / $344.39
| Professional | | $83.32 | $134.19 | $344.39 |