- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.04 / $130.37 / $153.38
| Facility | | $115.04 | $130.37 | $153.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.22 / $121.75 / $153.08
| Professional | | $93.22 | $121.75 | $153.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.00 / $177.91 / $260.16
| Professional | | $102.00 | $177.91 | $260.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.33 / $127.53 / $266.45
| Professional | | $110.33 | $127.53 | $266.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.00 / $126.12 / $197.35
| Professional | | $95.00 | $126.12 | $197.35 |