- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.51 / $151.21 / $310.73
| Facility | | $141.51 | $151.21 | $310.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.79 / $226.12 / $310.73
| Professional | | $130.79 | $226.12 | $310.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.00 / $240.00 / $240.00
| Professional | | $240.00 | $240.00 | $240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.69 / $217.66 / $340.66
| Professional | | $129.69 | $217.66 | $340.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.47 / $194.60 / $323.41
| Professional | | $130.47 | $194.60 | $323.41 |