- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.86 / $29.13 / $38.70
| Professional | | $16.86 | $29.13 | $38.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $406.05 / $986.72 / $1,164.72
| Facility | | $406.05 | $986.72 | $1,164.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.71 / $20.83 / $28.98
| Professional | | $17.71 | $20.83 | $28.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,224.34 / $2,224.34 / $2,224.34
| Facility | | $2,224.34 | $2,224.34 | $2,224.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.61 / $36.79 / $50.41
| Professional | | $21.61 | $36.79 | $50.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.32 / $25.93 / $40.86
| Professional | | $17.32 | $25.93 | $40.86 |