- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.00 / $2,562.00 / $4,050.00
| Facility | | $28.00 | $2,562.00 | $4,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.66 / $28.00 / $28.00
| Professional | | $16.66 | $28.00 | $28.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.03 / $0.03
| Facility | | $0.02 | $0.03 | $0.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.67 / $13.67 / $13.67
| Professional | | $13.67 | $13.67 | $13.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.67 / $6.24 / $11.37
| Professional | | $4.67 | $6.24 | $11.37 |