- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.70 / $103.66 / $109.33
| Facility | | $90.70 | $103.66 | $109.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.37 / $95.97 / $2,340.00
| Professional | | $86.37 | $95.97 | $2,340.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.63 / $194.63 / $194.63
| Facility | | $194.63 | $194.63 | $194.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.38 / $86.38 / $148.78
| Facility | | $86.38 | $86.38 | $148.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.38 / $86.38 / $86.38
| Professional | | $86.38 | $86.38 | $86.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.92 / $86.38 / $112.29
| Professional | | $82.92 | $86.38 | $112.29 |