- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.10 / $190.55 / $331.13
| Facility | | $87.10 | $190.55 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $109.65 / $162.18
| Professional | | $77.62 | $109.65 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $169.82 / $338.84
| Professional | | $81.28 | $169.82 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $81.28 / $131.83
| Professional | | $81.28 | $81.28 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $141.25 / $181.97
| Professional | | $123.03 | $141.25 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $144.54 / $190.55
| Professional | | $95.50 | $144.54 | $190.55 |