- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.19 / $137.46 / $309.23
| Facility | | $106.19 | $137.46 | $309.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.97 / $141.58 / $316.00
| Professional | | $88.97 | $141.58 | $316.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.08 / $183.84 / $302.88
| Professional | | $153.08 | $183.84 | $302.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.43 / $126.41 / $152.66
| Professional | | $96.43 | $126.41 | $152.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.85 / $202.76 / $229.52
| Professional | | $133.85 | $202.76 | $229.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.84 / $187.13 / $402.92
| Professional | | $123.84 | $187.13 | $402.92 |