- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.62 / $79.43 / $104.71
| Facility | | $77.62 | $79.43 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $109.65 / $257.04
| Professional | | $81.28 | $109.65 | $257.04 |
- 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
- $63.10 / $87.10 / $147.91
| Professional | | $63.10 | $87.10 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $125.89 / $169.82
| Professional | | $77.62 | $125.89 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $109.65 / $165.96
| Professional | | $85.11 | $109.65 | $165.96 |