- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82.61 / $82.61 / $115.43
| Facility | | $82.61 | $82.61 | $115.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.04 / $103.93 / $366.00
| Professional | | $70.04 | $103.93 | $366.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.96 / $161.12 / $202.48
| Professional | | $141.96 | $161.12 | $202.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.83 / $131.77 / $248.30
| Professional | | $84.83 | $131.77 | $248.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.86 / $138.44 / $262.04
| Professional | | $91.86 | $138.44 | $262.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.65 / $164.58 / $289.26
| Professional | | $121.65 | $164.58 | $289.26 |