- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.59 / $3,548.13 / $6,025.60
| Facility | | $12.59 | $3,548.13 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $12.02 / $21.38
| Professional | | $12.02 | $12.02 | $21.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,715.35 / $5,011.87
| Facility | | $3,162.28 | $3,715.35 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.59 / $12.59 / $12.59
| Professional | | $12.59 | $12.59 | $12.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.59 / $12.59 / $12.59
| Facility | | $12.59 | $12.59 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.59 / $12.59 / $12.59
| Professional | | $12.59 | $12.59 | $12.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.30 / $12.30 / $12.88
| Facility | | $12.30 | $12.30 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.30 / $12.59 / $12.59
| Professional | | $12.30 | $12.59 | $12.59 |