- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.25 / $1,850.93 / $3,731.13
| Facility | | $35.25 | $1,850.93 | $3,731.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.37 / $29.67 / $1,685.40
| Professional | | $29.37 | $29.67 | $1,685.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.23 / $29.23 / $29.38
| Professional | | $29.23 | $29.23 | $29.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.38 / $29.38 / $37.42
| Professional | | $29.38 | $29.38 | $37.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.38 / $29.38 / $32.92
| Professional | | $29.38 | $29.38 | $32.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.38 / $32.71 / $38.40
| Professional | | $29.38 | $32.71 | $38.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.66 / $27.66 / $27.66
| Professional | | $27.66 | $27.66 | $27.66 |