- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.31 / $4,095.67 / $14,450.10
| Facility | | $21.31 | $4,095.67 | $14,450.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $26.69
| Professional | | $21.31 | $21.31 | $26.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $34.67
| Professional | | $34.67 | $34.67 | $34.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $21.31
| Facility | | $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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $106.55 / $106.55
| Facility | | $75.00 | $106.55 | $106.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $31.51
| Professional | | $21.31 | $21.31 | $31.51 |