- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.16 / $21.20 / $2,792.75
| Facility | | $11.16 | $21.20 | $2,792.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.16 / $11.16 / $773.06
| Professional | | $11.16 | $11.16 | $773.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.50 / $112.50 / $112.50
| Professional | | $112.50 | $112.50 | $112.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.00 / $200.00 / $345.40
| Professional | | $120.00 | $200.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |