- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.28 / $141.25 / $354.81
| Facility | | $81.28 | $141.25 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $144.54 / $426.58
| Professional | | $104.71 | $144.54 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $114.82 / $186.21
| Professional | | $109.65 | $114.82 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $104.71 / $173.78
| Professional | | $70.79 | $104.71 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $173.78 / $302.00
| Professional | | $100.00 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $147.91 / $208.93
| Professional | | $104.71 | $147.91 | $208.93 |