- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.75 / $204.17 / $204.17
| Facility | | $2.75 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.45 / $25.12 / $426.58
| Professional | | $14.45 | $25.12 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $34.67
| Facility | | $34.67 | $34.67 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $5.25 / $5.25
| Professional | | $5.25 | $5.25 | $5.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38,018.94 / $38,018.94 / $38,018.94
| Professional | | $38,018.94 | $38,018.94 | $38,018.94 |