- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,319.33 / $2,319.33 / $14,469.22
| Facility | | $2,319.33 | $2,319.33 | $14,469.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.58 / $1,545.58 / $1,545.58
| Professional | | $1,545.58 | $1,545.58 | $1,545.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.03
| Facility | | $0.02 | $0.02 | $0.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,476.79 / $1,476.79 / $1,476.79
| Facility | | $1,476.79 | $1,476.79 | $1,476.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.66 / $660.66 / $660.66
| Professional | | $660.66 | $660.66 | $660.66 |