- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $92.58 / $105.74 / $138.56
| Facility | | $92.58 | $105.74 | $138.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.08 / $82.77 / $115.05
| Professional | | $63.08 | $82.77 | $115.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.00 / $91.00 / $131.08
| Professional | | $63.00 | $91.00 | $131.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.17 / $90.12 / $106.03
| Professional | | $72.17 | $90.12 | $106.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.03 / $106.85 / $131.05
| Professional | | $82.03 | $106.85 | $131.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $93.22 / $130.01
| Professional | | $75.00 | $93.22 | $130.01 |