- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $57.54 / $407.38
| Facility | | $39.81 | $57.54 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $457.09
| Professional | | $34.67 | $44.67 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $602.56 / $851.14
| Professional | | $234.42 | $602.56 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $50.12 / $60.26
| Professional | | $39.81 | $50.12 | $60.26 |