- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.53 / $344.51 / $685.64
| Facility | | $85.53 | $344.51 | $685.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.29 / $106.62 / $348.60
| Professional | | $82.29 | $106.62 | $348.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.81 / $364.25 / $1,225.80
| Professional | | $155.81 | $364.25 | $1,225.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.02 / $262.91 / $318.19
| Professional | | $209.02 | $262.91 | $318.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.68 / $178.00 / $576.37
| Professional | | $135.68 | $178.00 | $576.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.72 / $99.45 / $290.27
| Professional | | $70.72 | $99.45 | $290.27 |