- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.00 / $171.49 / $204.43
| Facility | | $102.00 | $171.49 | $204.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.63 / $173.25 / $543.49
| Professional | | $135.63 | $173.25 | $543.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.54 / $288.91 / $309.49
| Professional | | $247.54 | $288.91 | $309.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.05 / $224.46 / $357.77
| Professional | | $137.05 | $224.46 | $357.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.03 / $210.30 / $347.08
| Professional | | $0.03 | $210.30 | $347.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.31 / $259.76 / $481.50
| Professional | | $179.31 | $259.76 | $481.50 |