- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.53 / $140.47 / $170.04
| Facility | | $127.53 | $140.47 | $170.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.00 / $144.53 / $180.95
| Professional | | $125.00 | $144.53 | $180.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.03 / $151.03 / $151.03
| Professional | | $151.03 | $151.03 | $151.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.50 / $156.97 / $207.22
| Professional | | $109.50 | $156.97 | $207.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.12 / $187.53 / $321.99
| Professional | | $130.12 | $187.53 | $321.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.01 / $155.58 / $216.17
| Professional | | $121.01 | $155.58 | $216.17 |