- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,686.32 / $1,686.32 / $1,686.32
| Facility | | $1,686.32 | $1,686.32 | $1,686.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,227.04
| Professional | | $1,227.04 | $1,227.04 | $1,227.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.01 / $8.01 / $8.01
| Professional | | $8.01 | $8.01 | $8.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,930.88 / $4,930.88 / $4,930.88
| Professional | | $4,930.88 | $4,930.88 | $4,930.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,686.32 / $1,686.32 / $1,686.32
| Facility | | $1,686.32 | $1,686.32 | $1,686.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,227.04
| Professional | | $1,227.04 | $1,227.04 | $1,227.04 |