- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $551.21 / $3,949.56 / $7,796.52
| Facility | | $551.21 | $3,949.56 | $7,796.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $402.32
| Professional | | $402.32 | $402.32 | $402.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.03 / $0.03 / $20.01
| Professional | | $0.03 | $0.03 | $20.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.93 / $1,054.93 / $1,054.93
| Professional | | $1,054.93 | $1,054.93 | $1,054.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |