- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.28 / $115.91 / $237.89
| Facility | | $102.28 | $115.91 | $237.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.50 / $96.82 / $145.66
| Professional | | $76.50 | $96.82 | $145.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.50 / $142.87 / $144.91
| Professional | | $107.50 | $142.87 | $144.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Facility | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.73 / $98.34 / $174.00
| Professional | | $60.73 | $98.34 | $174.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.80 / $110.00 / $157.25
| Professional | | $83.80 | $110.00 | $157.25 |