- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.07 / $109.07 / $109.07
| Facility | | $109.07 | $109.07 | $109.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.75 / $112.53 / $148.46
| Professional | | $107.75 | $112.53 | $148.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.25 / $142.35 / $180.68
| Professional | | $131.25 | $142.35 | $180.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.67 / $175.84 / $217.52
| Professional | | $126.67 | $175.84 | $217.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.75 / $134.77 / $254.22
| Facility | | $107.75 | $134.77 | $254.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.03 / $157.12 / $1,352.50
| Professional | | $119.03 | $157.12 | $1,352.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.22 / $140.03 / $196.04
| Professional | | $116.22 | $140.03 | $196.04 |