- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $144.54
| Facility | | $109.65 | $109.65 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $131.83 / $177.83
| Professional | | $107.15 | $131.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $218.78
| Professional | | $204.17 | $204.17 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $154.88 / $245.47
| Professional | | $100.00 | $154.88 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $177.83 / $316.23
| Professional | | $85.11 | $177.83 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $141.25 / $275.42
| Professional | | $100.00 | $141.25 | $275.42 |