- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.43 / $208.26 / $228.86
| Facility | | $114.43 | $208.26 | $228.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.40 / $124.73 / $217.42
| Professional | | $90.40 | $124.73 | $217.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.00 / $70.00 / $70.00
| Facility | | $70.00 | $70.00 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $70.00 / $70.00
| Professional | | $70.00 | $70.00 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.75 / $131.75 / $164.68
| Professional | | $131.75 | $131.75 | $164.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.06 / $57.22 / $171.65
| Professional | | $48.06 | $57.22 | $171.65 |