- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.43 / $311.33 / $311.33
| Facility | | $0.43 | $311.33 | $311.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.05 / $180.10 / $311.33
| Professional | | $106.05 | $180.10 | $311.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.33 / $252.05 / $322.62
| Facility | | $142.33 | $252.05 | $322.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $2,000.00 / $3,900.00
| Professional | | $30.00 | $2,000.00 | $3,900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.87 / $342.87 / $342.87
| Professional | | $342.87 | $342.87 | $342.87 |