- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.42 / $130.66 / $185.19
| Facility | | $71.42 | $130.66 | $185.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.38 / $56.01 / $67.97
| Professional | | $54.38 | $56.01 | $67.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.00 / $65.00 / $65.00
| Professional | | $65.00 | $65.00 | $65.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.40 / $508.40 / $508.40
| Facility | | $508.40 | $508.40 | $508.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.42 / $170.42 / $311.58
| Professional | | $170.42 | $170.42 | $311.58 |