- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.41 / $170.45 / $419.77
| Facility | | $146.41 | $170.45 | $419.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.39 / $247.90 / $477.23
| Professional | | $22.39 | $247.90 | $477.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.60 / $12.60 / $12.60
| Professional | | $12.60 | $12.60 | $12.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.60 / $37.65 / $66.58
| Facility | | $6.60 | $37.65 | $66.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,895.32 / $1,895.32 / $1,895.32
| Facility | | $1,895.32 | $1,895.32 | $1,895.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.97 / $260.97 / $260.97
| Professional | | $260.97 | $260.97 | $260.97 |