- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.65 / $161.25 / $387.91
| Facility | | $113.65 | $161.25 | $387.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.58 / $154.30 / $240.27
| Professional | | $95.58 | $154.30 | $240.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.32 / $147.41 / $305.44
| Facility | | $103.32 | $147.41 | $305.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.94 / $138.27 / $219.09
| Professional | | $86.94 | $138.27 | $219.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.06 / $156.06 / $156.06
| Facility | | $156.06 | $156.06 | $156.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.00 / $876.00 / $876.00
| Professional | | $347.00 | $876.00 | $876.00 |