- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.13 / $177.91 / $190.57
| Facility | | $138.13 | $177.91 | $190.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.72 / $173.77 / $209.30
| Professional | | $136.72 | $173.77 | $209.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.76 / $220.76 / $220.76
| Professional | | $220.76 | $220.76 | $220.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.42 / $106.52 / $248.09
| Professional | | $99.42 | $106.52 | $248.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $50.00
| Professional | | $40.00 | $40.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.00 / $308.00 / $308.00
| Professional | | $308.00 | $308.00 | $308.00 |