- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.52 / $113.52 / $113.52
| Facility | | $113.52 | $113.52 | $113.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.16 / $112.62 / $323.00
| Professional | | $94.16 | $112.62 | $323.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.37 / $148.47 / $219.84
| Professional | | $104.37 | $148.47 | $219.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.03 / $140.30 / $227.41
| Professional | | $102.03 | $140.30 | $227.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $125.27 / $182.68
| Professional | | $1.00 | $125.27 | $182.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $104.39 / $156.59
| Professional | | $1.00 | $104.39 | $156.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.49 / $140.08 / $232.33
| Professional | | $109.49 | $140.08 | $232.33 |