- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.53 / $145.94 / $350.00
| Facility | | $128.53 | $145.94 | $350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.84 / $150.46 / $198.48
| Professional | | $130.84 | $150.46 | $198.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.33 / $194.54 / $292.92
| Professional | | $150.33 | $194.54 | $292.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.18 / $279.51 / $410.27
| Professional | | $115.18 | $279.51 | $410.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.41 / $225.64 / $292.20
| Professional | | $223.41 | $225.64 | $292.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.84 / $150.61 / $243.66
| Professional | | $130.84 | $150.61 | $243.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.64 / $233.35 / $301.74
| Professional | | $168.64 | $233.35 | $301.74 |