- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.53 / $158.53 / $215.36
| Facility | | $158.53 | $158.53 | $215.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $110.52 / $274.41
| Professional | | $70.00 | $110.52 | $274.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.21 / $153.32 / $224.95
| Professional | | $100.21 | $153.32 | $224.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.35 / $130.24 / $224.35
| Professional | | $92.35 | $130.24 | $224.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.75 / $124.10 / $227.93
| Professional | | $46.75 | $124.10 | $227.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.04 / $179.56 / $230.50
| Professional | | $107.04 | $179.56 | $230.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.13 / $161.43 / $240.91
| Professional | | $104.13 | $161.43 | $240.91 |