- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.08 / $241.08 / $441.32
| Facility | | $241.08 | $241.08 | $441.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.73 / $83.73 / $153.34
| Professional | | $83.73 | $83.73 | $153.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.61 / $150.30 / $150.30
| Professional | | $57.61 | $150.30 | $150.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.52 / $351.52 / $351.52
| Facility | | $351.52 | $351.52 | $351.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.23 / $272.08 / $492.13
| Professional | | $113.23 | $272.08 | $492.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.68 / $150.30 / $288.04
| Professional | | $15.68 | $150.30 | $288.04 |