- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $730.90 / $2,386.80 / $3,589.60
| Facility | | $730.90 | $2,386.80 | $3,589.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.06 / $1,145.06 / $1,409.05
| Professional | | $1,145.06 | $1,145.06 | $1,409.05 |
- 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
- $520.86 / $520.86 / $520.86
| Professional | | $520.86 | $520.86 | $520.86 |