- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,585.06 / $4,673.00 / $9,482.50
| Facility | | $2,585.06 | $4,673.00 | $9,482.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.00 / $2,843.00 / $7,631.00
| Professional | | $1,161.00 | $2,843.00 | $7,631.00 |
- 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 / $0.03
| Professional | | $0.02 | $0.02 | $0.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.76 / $65.76 / $65.76
| Facility | | $65.76 | $65.76 | $65.76 |