- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.22 / $158.26 / $339.34
| Facility | | $103.22 | $158.26 | $339.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.22 / $103.22 / $103.22
| Professional | | $103.22 | $103.22 | $103.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.98 / $168.62 / $312.70
| Facility | | $114.98 | $168.62 | $312.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.19 / $101.19 / $103.21
| Professional | | $101.19 | $101.19 | $103.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.07 / $101.19 / $112.32
| Professional | | $91.07 | $101.19 | $112.32 |