- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.30 / $2,707.39 / $2,850.48
| Facility | | $23.30 | $2,707.39 | $2,850.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.30 / $30.47 / $38.76
| Professional | | $23.30 | $30.47 | $38.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.08 / $54.16 / $71.22
| Professional | | $52.08 | $54.16 | $71.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.30 / $27.96 / $129.18
| Facility | | $23.30 | $27.96 | $129.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.32 / $25.98 / $39.04
| Professional | | $17.32 | $25.98 | $39.04 |