- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.56 / $4,473.24 / $21,613.57
| Facility | | $52.56 | $4,473.24 | $21,613.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.56 / $52.56 / $8,523.79
| Professional | | $52.56 | $52.56 | $8,523.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.35 / $63.86 / $70.56
| Facility | | $54.35 | $63.86 | $70.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.31 / $45.31 / $45.31
| Professional | | $45.31 | $45.31 | $45.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.31 / $45.31 / $124.28
| Facility | | $45.31 | $45.31 | $124.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.31 / $45.31 / $50.75
| Professional | | $45.31 | $45.31 | $50.75 |