- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.55 / $105.34 / $231.32
| Facility | | $77.55 | $105.34 | $231.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.98 / $152.40 / $231.32
| Professional | | $102.98 | $152.40 | $231.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.00 / $205.00 / $205.00
| Professional | | $205.00 | $205.00 | $205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.97 / $154.08 / $234.88
| Professional | | $96.97 | $154.08 | $234.88 |
- 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
- $53.73 / $116.45 / $201.28
| Professional | | $53.73 | $116.45 | $201.28 |