- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.00 / $104.00 / $142.21
| Facility | | $104.00 | $104.00 | $142.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.17 / $135.58 / $426.00
| Professional | | $88.17 | $135.58 | $426.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.94 / $198.56 / $237.26
| Professional | | $174.94 | $198.56 | $237.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.09 / $154.87 / $278.35
| Professional | | $100.09 | $154.87 | $278.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.87 / $162.63 / $307.04
| Professional | | $107.87 | $162.63 | $307.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.63 / $192.85 / $338.93
| Professional | | $144.63 | $192.85 | $338.93 |