- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.52 / $105.28 / $120.32
| Facility | | $101.52 | $105.28 | $120.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.01 / $46.32 / $58.70
| Professional | | $30.01 | $46.32 | $58.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.66 / $43.66 / $43.66
| Facility | | $43.66 | $43.66 | $43.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.42 / $46.42 / $243.22
| Professional | | $46.42 | $46.42 | $243.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.52 / $96.32 / $105.20
| Facility | | $86.52 | $96.32 | $105.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.47 / $54.77 / $76.52
| Professional | | $36.47 | $54.77 | $76.52 |