- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.80 / $752.03 / $1,422.05
| Facility | | $5.80 | $752.03 | $1,422.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.81 / $5.81 / $5.81
| Professional | | $5.81 | $5.81 | $5.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.20 / $1,555.19 / $2,404.21
| Facility | | $1,285.20 | $1,555.19 | $2,404.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $473.24 / $473.24 / $473.24
| Facility | | $473.24 | $473.24 | $473.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.75 / $533.75 / $533.75
| Professional | | $533.75 | $533.75 | $533.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.81 / $6.10 / $103.91
| Facility | | $5.81 | $6.10 | $103.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |