- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.51 / $179.09 / $342.87
| Facility | | $175.51 | $179.09 | $342.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.01 / $137.35 / $179.09
| Professional | | $101.01 | $137.35 | $179.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.06 / $7.06 / $7.06
| Professional | | $7.06 | $7.06 | $7.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $200.00 / $229.28
| Professional | | $127.38 | $200.00 | $229.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $127.38 / $191.07
| Professional | | $127.38 | $127.38 | $191.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.87 / $342.87 / $342.87
| Professional | | $342.87 | $342.87 | $342.87 |