- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.12 / $125.12 / $125.12
| Facility | | $125.12 | $125.12 | $125.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.74 / $121.78 / $137.29
| Professional | | $100.74 | $121.78 | $137.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.33 / $144.33 / $148.69
| Professional | | $144.33 | $144.33 | $148.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.43 / $107.43 / $134.04
| Professional | | $107.43 | $107.43 | $134.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.35 / $125.12 / $168.91
| Facility | | $106.35 | $125.12 | $168.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.32 / $139.56 / $171.26
| Professional | | $108.32 | $139.56 | $171.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.15 / $138.44 / $210.16
| Professional | | $113.15 | $138.44 | $210.16 |