- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.90 / $93.90 / $106.57
| Facility | | $93.90 | $93.90 | $106.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.31 / $94.14 / $121.00
| Professional | | $77.31 | $94.14 | $121.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $76.80 / $101.85 / $167.56
| Facility | | $76.80 | $101.85 | $167.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.18 / $108.18 / $108.18
| Professional | | $108.18 | $108.18 | $108.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.81 / $127.81 / $127.81
| Facility | | $127.81 | $127.81 | $127.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.30 / $123.24 / $233.90
| Professional | | $89.30 | $123.24 | $233.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.91 / $127.56 / $181.11
| Professional | | $80.91 | $127.56 | $181.11 |