- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.08 / $676.54 / $1,202.40
| Facility | | $287.08 | $676.54 | $1,202.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.10 / $18.11 / $21.85
| Professional | | $18.10 | $18.11 | $21.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.03 / $18.03 / $18.10
| Professional | | $18.03 | $18.03 | $18.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.11 / $18.11 / $23.06
| Professional | | $18.11 | $18.11 | $23.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.11 / $18.11 / $20.13
| Professional | | $18.11 | $18.11 | $20.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.11 / $18.11 / $29.35
| Professional | | $18.11 | $18.11 | $29.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.39 / $17.39 / $17.39
| Professional | | $17.39 | $17.39 | $17.39 |