- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.08 / $2,611.88 / $5,041.14
| Facility | | $34.08 | $2,611.88 | $5,041.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.08 / $1,384.02 / $2,953.74
| Professional | | $34.08 | $1,384.02 | $2,953.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.35 / $36.84 / $42.00
| Facility | | $32.35 | $36.84 | $42.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.38 / $29.38 / $29.38
| Professional | | $29.38 | $29.38 | $29.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.42 / $55.64 / $77.58
| Facility | | $42.42 | $55.64 | $77.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.38 / $29.38 / $32.71
| Professional | | $29.38 | $29.38 | $32.71 |