- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $177.83 / $177.83
| Facility | | $138.04 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $154.88 / $223.87
| Professional | | $120.23 | $154.88 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $107.15 / $199.53
| Professional | | $100.00 | $107.15 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $50.12
| Professional | | $39.81 | $39.81 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | | $309.03 | $309.03 | $309.03 |