- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.07 / $524.07 / $524.07
| Facility | | $524.07 | $524.07 | $524.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.80 / $289.60 / $310.39
| Professional | | $16.80 | $289.60 | $310.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.87 / $2.87 / $2.87
| Professional | | $2.87 | $2.87 | $2.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $275.00
| Professional | | $150.00 | $150.00 | $275.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.82 / $186.79 / $1,766.43
| Facility | | $63.82 | $186.79 | $1,766.43 |