- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $120.23 / $190.55
| Facility | | $114.82 | $120.23 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $89.13 / $128.82
| Professional | | $67.61 | $89.13 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $75.86 / $109.65
| Professional | | $75.86 | $75.86 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $144.54 / $144.54
| Professional | | $97.72 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $128.82 / $190.55
| Professional | | $83.18 | $128.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $112.20 / $154.88
| Professional | | $91.20 | $112.20 | $154.88 |