- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.66 / $102.66 / $115.24
| Facility | | $102.66 | $102.66 | $115.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.30 / $102.66 / $154.83
| Professional | | $80.30 | $102.66 | $154.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.67 / $135.03 / $204.87
| Professional | | $101.67 | $135.03 | $204.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.44 / $93.67 / $116.28
| Professional | | $71.44 | $93.67 | $116.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.62 / $147.65 / $204.05
| Professional | | $97.62 | $147.65 | $204.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.20 / $126.36 / $190.89
| Professional | | $97.20 | $126.36 | $190.89 |