- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.82 / $6,534.11 / $6,534.11
| Facility | | $20.82 | $6,534.11 | $6,534.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.62 / $20.82 / $23.43
| Professional | | $19.62 | $20.82 | $23.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,008.96 / $2,147.01 / $3,856.66
| Facility | | $1,008.96 | $2,147.01 | $3,856.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.58 / $22.32 / $47.66
| Professional | | $20.58 | $22.32 | $47.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.82 / $21.67 / $35.45
| Facility | | $20.82 | $21.67 | $35.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.22 / $86.22 / $86.22
| Professional | | $86.22 | $86.22 | $86.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |