- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,028.93 / $11,028.93 / $11,028.93
| Facility | | $11,028.93 | $11,028.93 | $11,028.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.48 / $13.26 / $13.26
| Professional | | $12.48 | $13.26 | $13.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.26 / $13.26 / $13.26
| Facility | | $13.26 | $13.26 | $13.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.26 / $13.26 / $13.26
| Professional | | $13.26 | $13.26 | $13.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.48 / $13.00 / $21.07
| Professional | | $12.48 | $13.00 | $21.07 |