- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.46 / $692.76 / $2,812.63
| Facility | | $3.46 | $692.76 | $2,812.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.46 / $3.46 / $316.22
| Professional | | $3.46 | $3.46 | $316.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.98 / $217.98 / $217.98
| Professional | | $217.98 | $217.98 | $217.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.46 / $3.63 / $7.32
| Facility | | $3.46 | $3.63 | $7.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.87 / $375.85 / $375.85
| Professional | | $328.87 | $375.85 | $375.85 |