- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.00 / $93.00 / $132.46
| Facility | | $93.00 | $93.00 | $132.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.84 / $113.64 / $214.37
| Professional | | $78.84 | $113.64 | $214.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.50 / $199.19 / $236.65
| Professional | | $175.50 | $199.19 | $236.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.09 / $155.31 / $277.58
| Professional | | $100.09 | $155.31 | $277.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.87 / $162.25 / $307.04
| Professional | | $107.87 | $162.25 | $307.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.00 / $192.85 / $338.93
| Professional | | $140.00 | $192.85 | $338.93 |