- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.46 / $2,290.87 / $6,165.95
| Facility | | $6.46 | $2,290.87 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.46 / $1,023.29 / $3,388.44
| Professional | | $6.46 | $1,023.29 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.31 / $6.31 / $6.31
| Professional | | $6.31 | $6.31 | $6.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.88 / $33.88 / $33.88
| Facility | | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.46 / $6.46 / $9.77
| Professional | | $6.46 | $6.46 | $9.77 |