- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $239.88
| Facility | | $30.20 | $30.20 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $537.03
| Professional | | $30.20 | $44.67 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $25.70 / $26.92
| Professional | | $25.70 | $25.70 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $363.08 / $660.69
| Professional | | $223.87 | $363.08 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,570.40 / $5,623.41
| Facility | | $1,949.84 | $2,570.40 | $5,623.41 |