- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,609.27 / $1,609.27 / $2,735.75
| Facility | | $1,609.27 | $1,609.27 | $2,735.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.27 / $1,609.27 / $1,609.27
| Professional | | $1,609.27 | $1,609.27 | $1,609.27 |
- 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
- $1,609.27 / $1,609.27 / $2,450.92
| Facility | | $1,609.27 | $1,609.27 | $2,450.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,291.00 / $1,291.00 / $4,071.00
| Facility | | $1,291.00 | $1,291.00 | $4,071.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.00 / $1,291.00 / $4,071.00
| Professional | | $1,291.00 | $1,291.00 | $4,071.00 |