- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.55 / $111.70 / $310.00
| Facility | | $94.55 | $111.70 | $310.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.55 / $105.64 / $131.18
| Professional | | $94.55 | $105.64 | $131.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.14 / $127.97 / $363.37
| Professional | | $114.14 | $127.97 | $363.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.43 / $107.43 / $107.43
| Professional | | $107.43 | $107.43 | $107.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.43 / $107.43 / $107.43
| Professional | | $107.43 | $107.43 | $107.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.84 / $148.65 / $208.79
| Professional | | $109.84 | $148.65 | $208.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.36 / $148.74 / $225.03
| Professional | | $111.36 | $148.74 | $225.03 |