- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.27 / $5,745.79 / $9,423.00
| Facility | | $24.27 | $5,745.79 | $9,423.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.30 / $21.51 / $7,023.00
| Professional | | $21.30 | $21.51 | $7,023.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $22.06
| Professional | | $21.31 | $21.31 | $22.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $27.14
| Professional | | $21.31 | $21.31 | $27.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $33.36
| Professional | | $21.31 | $21.31 | $33.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $22.59
| Professional | | $21.31 | $21.31 | $22.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.67 / $21.67 / $21.67
| Professional | | $21.67 | $21.67 | $21.67 |