- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.89 / $104.62 / $636.09
| Facility | | $93.89 | $104.62 | $636.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.62 / $104.62 / $107.30
| Professional | | $104.62 | $104.62 | $107.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.13 / $140.84 / $185.10
| Professional | | $134.13 | $140.84 | $185.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.37 / $272.00 / $764.74
| Facility | | $89.37 | $272.00 | $764.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.28 / $134.13 / $143.52
| Facility | | $103.28 | $134.13 | $143.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.33 / $80.48 / $122.14
| Professional | | $56.33 | $80.48 | $122.14 |