- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.85 / $162.41 / $762.85
| Facility | | $129.85 | $162.41 | $762.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.39 / $177.72 / $247.90
| Professional | | $22.39 | $177.72 | $247.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.05 / $108.00 / $135.69
| Professional | | $1.05 | $108.00 | $135.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.40 / $53.55 / $75.66
| Facility | | $5.40 | $53.55 | $75.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.00 / $496.00 / $496.00
| Facility | | $496.00 | $496.00 | $496.00 |