- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $208.93 / $478.63
| Facility | | $47.86 | $208.93 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $57.54 / $309.03
| Professional | | $30.20 | $57.54 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $79.43 / $87.10
| Professional | | $64.57 | $79.43 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $158.49 / $218.78
| Professional | | $89.13 | $158.49 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $4,168.69
| Facility | | $2,511.89 | $2,511.89 | $4,168.69 |