- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.71 / $28.00 / $28.00
| Professional | | $5.71 | $28.00 | $28.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.04 / $14.63 / $17.50
| Facility | | $12.04 | $14.63 | $17.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.49 / $7.21 / $10.38
| Professional | | $5.49 | $7.21 | $10.38 |