- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.06 / $163.26 / $175.82
| Facility | | $70.06 | $163.26 | $175.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.06 / $70.06 / $169.56
| Professional | | $70.06 | $70.06 | $169.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.04 / $84.04 / $84.04
| Professional | | $84.04 | $84.04 | $84.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.84 / $92.06 / $237.32
| Professional | | $72.84 | $92.06 | $237.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.81 / $163.71 / $163.71
| Professional | | $74.81 | $163.71 | $163.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.52 / $156.31 / $207.32
| Professional | | $61.52 | $156.31 | $207.32 |