- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.01 / $32.53 / $32.53
| Facility | | $28.01 | $32.53 | $32.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.52 / $31.77 / $32.53
| Professional | | $28.52 | $31.77 | $32.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.05 / $48.30 / $48.30
| Professional | | $41.05 | $48.30 | $48.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53,899.46 / $53,899.46 / $53,899.46
| Facility | | $53,899.46 | $53,899.46 | $53,899.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $45.00
| Professional | | $45.00 | $45.00 | $45.00 |