- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.22 / $158.22 / $671.30
| Facility | | $158.22 | $158.22 | $671.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.92 / $158.22 / $170.21
| Professional | | $111.92 | $158.22 | $170.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.13 / $180.75 / $240.48
| Professional | | $137.13 | $180.75 | $240.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $38.81 / $199.94
| Professional | | $32.34 | $38.81 | $199.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.31 / $248.40 / $306.38
| Professional | | $196.31 | $248.40 | $306.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.11 / $154.11 / $251.94
| Professional | | $139.11 | $154.11 | $251.94 |