- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.12 / $105.12 / $105.12
| Facility | | $105.12 | $105.12 | $105.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.50 / $105.55 / $125.56
| Professional | | $94.50 | $105.55 | $125.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.62 / $216.29 / $247.46
| Facility | | $167.62 | $216.29 | $247.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.97 / $126.97 / $134.91
| Professional | | $126.97 | $126.97 | $134.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.47 / $166.47 / $166.47
| Facility | | $166.47 | $166.47 | $166.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.52 / $121.52 / $166.47
| Professional | | $121.52 | $121.52 | $166.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.59 / $140.59 / $140.59
| Facility | | $140.59 | $140.59 | $140.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.59 / $151.40 / $216.29
| Professional | | $140.59 | $151.40 | $216.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.31 / $134.31 / $134.31
| Professional | | $134.31 | $134.31 | $134.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.35 / $107.90 / $162.52
| Professional | | $82.35 | $107.90 | $162.52 |