- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.00 / $128.00 / $128.00
| Facility | | $128.00 | $128.00 | $128.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.31 / $136.93 / $288.07
| Professional | | $102.31 | $136.93 | $288.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.02 / $101.86 / $387.74
| Professional | | $100.02 | $101.86 | $387.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.12 / $180.25 / $398.40
| Professional | | $104.12 | $180.25 | $398.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.55 / $194.83 / $367.29
| Professional | | $150.55 | $194.83 | $367.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.23 / $156.41 / $385.78
| Professional | | $110.23 | $156.41 | $385.78 |