- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.02 / $719.15 / $1,287.48
| Facility | | $3.02 | $719.15 | $1,287.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $3.02 / $309.27
| Professional | | $3.02 | $3.02 | $309.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $3.02 / $3.02
| Professional | | $3.02 | $3.02 | $3.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.55 / $196.10 / $343.35
| Facility | | $8.55 | $196.10 | $343.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $4.53 / $38.54
| Professional | | $3.02 | $4.53 | $38.54 |