- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.44 / $3.44 / $13,135.78
| Facility | | $3.44 | $3.44 | $13,135.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.44 / $3.44 / $3.50
| Professional | | $3.44 | $3.44 | $3.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.85 / $3.81 / $4.19
| Professional | | $2.85 | $3.81 | $4.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.56 / $119.56 / $119.56
| Professional | | $119.56 | $119.56 | $119.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38,249.62 / $38,249.62 / $38,249.62
| Professional | | $38,249.62 | $38,249.62 | $38,249.62 |