- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.07 / $132.74 / $145.96
| Facility | | $103.07 | $132.74 | $145.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.07 / $145.96 / $165.16
| Professional | | $103.07 | $145.96 | $165.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.40 / $163.40 / $163.40
| Professional | | $163.40 | $163.40 | $163.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.66 / $165.11 / $282.14
| Professional | | $121.66 | $165.11 | $282.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $50.00
| Professional | | $40.00 | $40.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.00 / $118.00 / $118.00
| Professional | | $118.00 | $118.00 | $118.00 |