- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.32 / $17.32 / $47.52
| Facility | | $17.32 | $17.32 | $47.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.32 / $21.35 / $27.64
| Professional | | $17.32 | $21.35 | $27.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.55 / $83.00 / $114.54
| Professional | | $70.55 | $83.00 | $114.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,326.96 / $16,433.53 / $23,233.46
| Facility | | $15,326.96 | $16,433.53 | $23,233.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.21 / $38.61 / $38.61
| Professional | | $25.21 | $38.61 | $38.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.00 / $92.00 / $105.00
| Professional | | $76.00 | $92.00 | $105.00 |