- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.71 / $212.98 / $769.12
| Facility | | $153.71 | $212.98 | $769.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.08 / $124.08 / $153.72
| Professional | | $124.08 | $124.08 | $153.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.31 / $104.46 / $276.56
| Professional | | $94.31 | $104.46 | $276.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $492.63 / $866.27 / $896.59
| Facility | | $492.63 | $866.27 | $896.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.78 / $111.12 / $407.44
| Professional | | $77.78 | $111.12 | $407.44 |