- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.50 / $119.50 / $152.84
| Facility | | $119.50 | $119.50 | $152.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.43 / $102.71 / $119.50
| Professional | | $96.43 | $102.71 | $119.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.20 / $143.21 / $184.37
| Professional | | $108.20 | $143.21 | $184.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.24 / $141.06 / $141.06
| Professional | | $101.24 | $141.06 | $141.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.98 / $120.98 / $176.62
| Professional | | $99.98 | $120.98 | $176.62 |