- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.40 / $161.07 / $888.33
| Facility | | $145.40 | $161.07 | $888.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.33 / $129.60 / $173.24
| Professional | | $101.33 | $129.60 | $173.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.04 / $152.99 / $199.76
| Professional | | $130.04 | $152.99 | $199.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.00 / $135.52 / $278.37
| Professional | | $106.00 | $135.52 | $278.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.56 / $146.83 / $213.11
| Professional | | $104.56 | $146.83 | $213.11 |