- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.05 / $282.58 / $289.19
| Facility | | $139.05 | $282.58 | $289.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.50 / $140.25 / $191.10
| Professional | | $109.50 | $140.25 | $191.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.84 / $140.00 / $236.28
| Professional | | $69.84 | $140.00 | $236.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.13 / $147.42 / $186.67
| Professional | | $120.13 | $147.42 | $186.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.80 / $158.41 / $198.01
| Professional | | $129.80 | $158.41 | $198.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.84 / $152.71 / $221.87
| Professional | | $112.84 | $152.71 | $221.87 |