- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.00 / $107.67 / $137.80
| Facility | | $102.00 | $107.67 | $137.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.00 / $117.13 / $179.60
| Professional | | $84.00 | $117.13 | $179.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.72 / $202.23 / $212.81
| Professional | | $172.72 | $202.23 | $212.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.10 / $152.16 / $242.28
| Professional | | $90.10 | $152.16 | $242.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.03 / $132.58 / $215.83
| Professional | | $0.03 | $132.58 | $215.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.95 / $173.75 / $337.05
| Professional | | $125.95 | $173.75 | $337.05 |