- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $10.00 / $12.02
| Professional | | $10.00 | $10.00 | $12.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $3,162.28
| Facility | | $1,995.26 | $2,344.23 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $10.47 / $10.47
| Professional | | $10.47 | $10.47 | $10.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.47 / $10.47 / $10.47
| Facility | | $10.47 | $10.47 | $10.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $10.47 / $11.22
| Professional | | $10.47 | $10.47 | $11.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.47 / $10.47 / $10.96
| Facility | | $10.47 | $10.47 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.91 / $10.47 / $12.02
| Professional | | $8.91 | $10.47 | $12.02 |