- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $12.02 / $54.95
| Professional | | $12.02 | $12.02 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.18 / $32.36 / $75.86
| Facility | | $13.18 | $32.36 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.13 / $8.13 / $8.91
| Professional | | $8.13 | $8.13 | $8.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.02 / $12.02 / $12.02
| Facility | | $12.02 | $12.02 | $12.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.31 / $3.31 / $3.31
| Professional | | $3.31 | $3.31 | $3.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,000.00 / $10,964.78
| Facility | | $7,413.10 | $10,000.00 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,000.00 / $10,964.78
| Professional | | $7,413.10 | $10,000.00 | $10,964.78 |