- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.32 / $208.32 / $208.32
| Facility | | $208.32 | $208.32 | $208.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.84 / $146.58 / $336.60
| Professional | | $82.84 | $146.58 | $336.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Facility | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $3,200.00
| Professional | | $0.02 | $0.02 | $3,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36,749.62 / $36,749.62 / $36,749.62
| Professional | | $36,749.62 | $36,749.62 | $36,749.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.36 / $379.20 / $973.59
| Facility | | $233.36 | $379.20 | $973.59 |