- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.71 / $295.54 / $1,072.66
| Facility | | $8.71 | $295.54 | $1,072.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.81 / $5.81 / $5.81
| Professional | | $5.81 | $5.81 | $5.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.30 / $96.80 / $96.80
| Professional | | $72.30 | $96.80 | $96.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,490.51 / $2,490.51 / $2,490.51
| Facility | | $2,490.51 | $2,490.51 | $2,490.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.81 / $6.54 / $13.57
| Facility | | $5.81 | $6.54 | $13.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.92 / $656.92 / $656.92
| Professional | | $656.92 | $656.92 | $656.92 |