- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.38 / $107.67 / $107.67
| Facility | | $104.38 | $107.67 | $107.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.24 / $104.38 / $110.90
| Professional | | $88.24 | $104.38 | $110.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.73 / $239.10 / $264.62
| Professional | | $200.73 | $239.10 | $264.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.85 / $116.28 / $146.21
| Professional | | $92.85 | $116.28 | $146.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.38 / $129.49 / $207.72
| Facility | | $104.38 | $129.49 | $207.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.71 / $196.11 / $661.18
| Professional | | $109.71 | $196.11 | $661.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.05 / $170.24 / $249.30
| Professional | | $99.05 | $170.24 | $249.30 |