- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $281.84 / $281.84
| Professional | | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $288.40 / $575.44
| Facility | | $109.65 | $288.40 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54,954.09 / $54,954.09 / $54,954.09
| Professional | | $54,954.09 | $54,954.09 | $54,954.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $50.12 / $50.12
| Professional | | $50.12 | $50.12 | $50.12 |