- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.53 / $161.87 / $3,347.68
| Facility | | $135.53 | $161.87 | $3,347.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.74 / $9.74 / $2,673.50
| Professional | | $9.74 | $9.74 | $2,673.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.61 / $12.61 / $14.12
| Professional | | $12.61 | $12.61 | $14.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.40 / $125.40 / $125.40
| Professional | | $125.40 | $125.40 | $125.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.81 / $49.55 / $249.50
| Facility | | $10.81 | $49.55 | $249.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.00 / $155.00 / $329.00
| Professional | | $155.00 | $155.00 | $329.00 |