- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.83 / $111.83 / $111.83
| Facility | | $111.83 | $111.83 | $111.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.37 / $90.93 / $136.78
| Professional | | $68.37 | $90.93 | $136.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.08 / $145.15 / $215.92
| Professional | | $104.08 | $145.15 | $215.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.17 / $94.06 / $113.84
| Professional | | $72.17 | $94.06 | $113.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.03 / $101.57 / $186.84
| Professional | | $85.03 | $101.57 | $186.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.80 / $134.63 / $185.85
| Professional | | $100.80 | $134.63 | $185.85 |