- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.11 / $1,380.38 / $3,801.89
| Facility | | $33.11 | $1,380.38 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.18 / $33.88 / $46.77
| Professional | | $28.18 | $33.88 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.84 / $45.71 / $51.29
| Professional | | $28.84 | $45.71 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.48 / $35.48 / $35.48
| Professional | | $35.48 | $35.48 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $125.89
| Professional | | $112.20 | $112.20 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $60.26 / $89.13
| Professional | | $41.69 | $60.26 | $89.13 |