- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.20 / $105.20 / $133.52
| Facility | | $105.20 | $105.20 | $133.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.52 / $105.95 / $161.71
| Professional | | $90.52 | $105.95 | $161.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.17 / $211.39 / $410.48
| Facility | | $192.17 | $211.39 | $410.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.54 / $117.05 / $158.54
| Professional | | $112.54 | $117.05 | $158.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.31 / $124.31 / $124.31
| Facility | | $124.31 | $124.31 | $124.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.75 / $90.75 / $222.75
| Professional | | $90.75 | $90.75 | $222.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.06 / $95.87 / $153.12
| Professional | | $75.06 | $95.87 | $153.12 |