- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,609.27 / $1,609.27 / $2,325.99
| Facility | | $1,609.27 | $1,609.27 | $2,325.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.27 / $1,609.27 / $2,114.64
| Professional | | $1,609.27 | $1,609.27 | $2,114.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,456.92 / $5,821.21 / $8,577.84
| Facility | | $5,456.92 | $5,821.21 | $8,577.84 |
- 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
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |