- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.50 / $138.90 / $543.12
| Facility | | $105.50 | $138.90 | $543.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.03 / $110.25 / $197.40
| Professional | | $57.03 | $110.25 | $197.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.00 / $178.00 / $178.00
| Professional | | $178.00 | $178.00 | $178.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.22 / $101.75 / $179.78
| Professional | | $72.22 | $101.75 | $179.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $68.00
| Professional | | $17.00 | $20.00 | $68.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.73 / $91.62 / $149.65
| Professional | | $59.73 | $91.62 | $149.65 |