- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,897.79 / $4,897.79
| Facility | | $1,202.26 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,513.56
| Professional | | $1,202.26 | $1,202.26 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.05
| Facility | | $0.02 | $0.02 | $0.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,897.79 / $6,918.31
| Facility | | $1,202.26 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,479.11
| Professional | | $1,202.26 | $1,202.26 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $1,258.93 / $2,041.74
| Facility | | $467.74 | $1,258.93 | $2,041.74 |