- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.25 / $95.94 / $161.50
| Facility | | $86.25 | $95.94 | $161.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.57 / $98.09 / $161.50
| Professional | | $85.57 | $98.09 | $161.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.00 / $106.00 / $106.00
| Professional | | $106.00 | $106.00 | $106.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.05 / $112.00 / $148.31
| Professional | | $81.05 | $112.00 | $148.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.93 / $105.24 / $163.03
| Professional | | $78.93 | $105.24 | $163.03 |