- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.13 / $1,686.40 / $2,340.83
| Facility | | $8.13 | $1,686.40 | $2,340.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.81 / $5.81 / $178.52
| Professional | | $5.81 | $5.81 | $178.52 |
- 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
- $171.28 / $171.28 / $533.75
| Professional | | $171.28 | $171.28 | $533.75 |
- 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
- $656.92 / $656.92 / $656.92
| Professional | | $656.92 | $656.92 | $656.92 |