- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $169.82 / $501.19
| Facility | | $144.54 | $169.82 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $120.23 / $316.23
| Professional | | $107.15 | $120.23 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $177.83 / $257.04
| Professional | | $100.00 | $177.83 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $281.84 / $380.19
| Professional | | $109.65 | $281.84 | $380.19 |