- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,884.03 / $2,884.03
| Facility | | $1,000.00 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $2.00 / $7.08
| Professional | | $1.00 | $2.00 | $7.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.96 / $10.96 / $10.96
| Professional | | $10.96 | $10.96 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.51 / $8.51 / $10.72
| Professional | | $8.51 | $8.51 | $10.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.33 / $11.22 / $14.13
| Professional | | $9.33 | $11.22 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $4.27 / $10.96
| Professional | | $3.02 | $4.27 | $10.96 |