- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.25 / $220.00 / $331.00
| Facility | | $21.25 | $220.00 | $331.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $38.00 / $302.44
| Professional | | $21.25 | $38.00 | $302.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.80 / $174.84 / $290.88
| Professional | | $142.80 | $174.84 | $290.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $206.10 / $276.72
| Professional | | $150.00 | $206.10 | $276.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.08 / $260.00 / $410.56
| Professional | | $194.08 | $260.00 | $410.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.00 / $50.00 / $78.00
| Professional | | $37.00 | $50.00 | $78.00 |