- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.86 / $954.99 / $954.99
| Facility | | $75.86 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $85.11 / $186.21
| Professional | | $75.86 | $85.11 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $100.00 / $134.90
| Professional | | $79.43 | $100.00 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $125.89 / $213.80
| Professional | | $87.10 | $125.89 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $109.65 / $446.68
| Professional | | $83.18 | $109.65 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $114.82 / $194.98
| Professional | | $85.11 | $114.82 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $117.49 / $213.80
| Professional | | $79.43 | $117.49 | $213.80 |