- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.52 / $16.52 / $458.50
| Facility | | $16.52 | $16.52 | $458.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.53 / $27.10 / $458.50
| Professional | | $12.53 | $27.10 | $458.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.53 / $13.45 / $13.45
| Professional | | $12.53 | $13.45 | $13.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.16 / $45.84 / $1,162.81
| Professional | | $12.16 | $45.84 | $1,162.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.52 / $1,031.13 / $1,031.13
| Professional | | $427.52 | $1,031.13 | $1,031.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.68 / $360.27 / $400.30
| Professional | | $61.68 | $360.27 | $400.30 |