- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.33 / $109.61 / $146.15
| Facility | | $69.33 | $109.61 | $146.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.70 / $124.50 / $167.43
| Professional | | $71.70 | $124.50 | $167.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.00 / $143.00 / $143.00
| Professional | | $143.00 | $143.00 | $143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.81 / $113.84 / $191.39
| Professional | | $78.81 | $113.84 | $191.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.44 / $164.84 / $208.80
| Professional | | $133.44 | $164.84 | $208.80 |