- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.00 / $110.71 / $149.47
| Facility | | $80.00 | $110.71 | $149.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.06 / $110.72 / $149.47
| Professional | | $85.06 | $110.72 | $149.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.72 / $195.04 / $262.39
| Facility | | $160.72 | $195.04 | $262.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.39 / $107.38 / $126.71
| Professional | | $78.39 | $107.38 | $126.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.06 / $102.71 / $191.16
| Professional | | $71.06 | $102.71 | $191.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.91 / $94.55 / $130.19
| Professional | | $70.91 | $94.55 | $130.19 |