- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $664.12 / $1,269.59 / $3,581.00
| Facility | | $664.12 | $1,269.59 | $3,581.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.78 / $507.78 / $883.94
| Professional | | $507.78 | $507.78 | $883.94 |
- 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
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.34 / $489.34 / $489.34
| Professional | | $489.34 | $489.34 | $489.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,345.36 / $3,835.70 / $4,184.46
| Facility | | $2,345.36 | $3,835.70 | $4,184.46 |