- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $117.49 / $117.49
| Facility | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $181.97 / $181.97
| Professional | | $117.49 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.22 / $11.22 / $95.50
| Professional | | $11.22 | $11.22 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218,776.16 / $524,807.46 / $954,992.59
| Facility | | $218,776.16 | $524,807.46 | $954,992.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Professional | | $177.83 | $177.83 | $177.83 |