- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,754.23
| Facility | | $1,621.81 | $1,621.81 | $2,754.23 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,951.21
| Facility | | $1,621.81 | $1,621.81 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $1,288.25 / $4,073.80
| Facility | | $64.57 | $1,288.25 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $1,288.25 / $4,073.80
| Professional | | $64.57 | $1,288.25 | $4,073.80 |