- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.13 / $25.12 / $97.72
| Professional | | $8.13 | $25.12 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $39.81 / $52.48
| Professional | | $33.88 | $39.81 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $16.98 / $16.98
| Professional | | $16.98 | $16.98 | $16.98 |