- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.98 / $0.99 / $78.40
| Facility | | $0.98 | $0.99 | $78.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.75 / $2,636.40 / $2,636.40
| Professional | | $351.75 | $2,636.40 | $2,636.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,147.00 / $3,147.00 / $3,147.00
| Professional | | $3,147.00 | $3,147.00 | $3,147.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.00 / $507.00 / $641.21
| Facility | | $507.00 | $507.00 | $641.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.00 / $36.00 / $41.00
| Facility | | $36.00 | $36.00 | $41.00 |