- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.62 / $96.62 / $96.62
| Facility | | $96.62 | $96.62 | $96.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.41 / $100.76 / $120.30
| Professional | | $92.41 | $100.76 | $120.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.28 / $124.95 / $223.11
| Professional | | $109.28 | $124.95 | $223.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $232.04
| Professional | | $141.06 | $141.06 | $232.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.19 / $153.96 / $234.38
| Professional | | $117.19 | $153.96 | $234.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.56 / $136.19 / $278.36
| Professional | | $96.56 | $136.19 | $278.36 |