- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.67 / $478.63 / $1,348.96
| Facility | | $44.67 | $478.63 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $162.18
| Professional | | $43.65 | $43.65 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $123.03 / $123.03
| Professional | | $81.28 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.67 / $44.67 / $162.18
| Facility | | $44.67 | $44.67 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |