- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.08 / $104.08 / $109.20
| Facility | | $104.08 | $104.08 | $109.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.82 / $105.43 / $129.16
| Professional | | $84.82 | $105.43 | $129.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.36 / $126.60 / $143.37
| Facility | | $125.36 | $126.60 | $143.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.80 / $124.86 / $212.06
| Professional | | $104.80 | $124.86 | $212.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.10 / $124.10 / $124.10
| Facility | | $124.10 | $124.10 | $124.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.42 / $96.42 / $96.42
| Professional | | $96.42 | $96.42 | $96.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.82 / $129.08 / $229.11
| Professional | | $100.82 | $129.08 | $229.11 |