- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $630.96 / $660.69
| Facility | | $30.20 | $630.96 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $57.54 / $691.83
| Professional | | $30.20 | $57.54 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $3.72 / $6.92
| Professional | | $3.02 | $3.72 | $6.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $426.58 / $562.34
| Professional | | $275.42 | $426.58 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $426.58 / $457.09
| Professional | | $251.19 | $426.58 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $67.61 / $100.00
| Professional | | $45.71 | $67.61 | $100.00 |