- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.53 / $214.40 / $852.50
| Facility | | $54.53 | $214.40 | $852.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.09 / $52.85 / $57.50
| Professional | | $34.09 | $52.85 | $57.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.00 / $123.00 / $289.05
| Professional | | $123.00 | $123.00 | $289.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.66 / $5,062.89 / $5,062.89
| Facility | | $115.66 | $5,062.89 | $5,062.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.94 / $402.94 / $572.40
| Professional | | $402.94 | $402.94 | $572.40 |