- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.46 / $314.45 / $766.64
| Facility | | $3.46 | $314.45 | $766.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.46 / $3.46 / $424.92
| Professional | | $3.46 | $3.46 | $424.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.51 / $903.51 / $1,807.00
| Professional | | $903.51 | $903.51 | $1,807.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $397.64 / $397.64 / $397.64
| Facility | | $397.64 | $397.64 | $397.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.98 / $217.98 / $217.98
| Professional | | $217.98 | $217.98 | $217.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |