- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $76.75 / $80.47 / $168.53
| Facility | | $76.75 | $80.47 | $168.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.75 / $92.57 / $168.53
| Professional | | $76.75 | $92.57 | $168.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.00 / $141.00 / $141.00
| Professional | | $141.00 | $141.00 | $141.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.20 / $116.06 / $174.15
| Professional | | $71.20 | $116.06 | $174.15 |
- 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
- $73.44 / $98.73 / $194.74
| Professional | | $73.44 | $98.73 | $194.74 |