- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $389.05
| Facility | | $34.67 | $44.67 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $50.12 / $512.86
| Professional | | $34.67 | $50.12 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $25.12 / $38.90
| Professional | | $16.98 | $25.12 | $38.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,290.87 / $2,951.21
| Facility | | $1,659.59 | $2,290.87 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Professional | | $4,466.84 | $4,466.84 | $4,466.84 |