- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.26 / $9,262.12 / $26,624.14
| Facility | | $69.26 | $9,262.12 | $26,624.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.51 / $22.16
| Professional | | $21.31 | $21.51 | $22.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.06 / $22.06 / $31.82
| Facility | | $22.06 | $22.06 | $31.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $21.31
| Professional | | $21.31 | $21.31 | $21.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.10 / $21.31 / $21.31
| Facility | | $20.10 | $21.31 | $21.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $21.31
| Professional | | $21.31 | $21.31 | $21.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $21.31
| Professional | | $21.31 | $21.31 | $21.31 |