- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $138.04
| Facility | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $128.82 / $177.83
| Professional | | $100.00 | $128.82 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $141.25 / $223.87
| Professional | | $100.00 | $141.25 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $190.55
| Professional | | $32.36 | $33.11 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $158.49 / $218.78
| Professional | | $114.82 | $158.49 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $158.49 / $186.21
| Professional | | $141.25 | $158.49 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $177.83 / $309.03
| Professional | | $131.83 | $177.83 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $144.54 / $213.80
| Professional | | $104.71 | $144.54 | $213.80 |