- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.94 / $112.24 / $152.26
| Facility | | $105.94 | $112.24 | $152.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.63 / $102.71 / $121.22
| Professional | | $93.63 | $102.71 | $121.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.62 / $115.74 / $149.34
| Professional | | $100.62 | $115.74 | $149.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.43 / $141.06 / $141.06
| Professional | | $95.43 | $141.06 | $141.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.57 / $123.67 / $201.91
| Professional | | $0.57 | $123.67 | $201.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.57 / $101.39 / $252.39
| Professional | | $0.57 | $101.39 | $252.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.65 / $131.87 / $236.18
| Professional | | $97.65 | $131.87 | $236.18 |