- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $141.25 / $199.53
| Facility | | $114.82 | $141.25 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $128.82 / $169.82
| Professional | | $107.15 | $128.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $151.36 / $257.04
| Professional | | $100.00 | $151.36 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $144.54 / $229.09
| Professional | | $104.71 | $144.54 | $229.09 |