- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.07 / $105.07 / $143.19
| Facility | | $105.07 | $105.07 | $143.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.48 / $105.07 / $131.07
| Professional | | $74.48 | $105.07 | $131.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.37 / $151.37 / $151.37
| Professional | | $151.37 | $151.37 | $151.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.31 / $130.12 / $130.12
| Professional | | $98.31 | $130.12 | $130.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.54 / $96.42 / $96.42
| Professional | | $58.54 | $96.42 | $96.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.08 / $174.08 / $174.08
| Professional | | $174.08 | $174.08 | $174.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.24 / $126.80 / $203.32
| Professional | | $97.24 | $126.80 | $203.32 |