- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,090.30 / $7,585.78
| Facility | | $1,621.81 | $3,090.30 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,137.96
| Professional | | $1,621.81 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,659.59 / $2,818.38
| Facility | | $1,621.81 | $1,659.59 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |