- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.72 / $1,751.72 / $1,751.72
| Facility | | $1,751.72 | $1,751.72 | $1,751.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.00 / $1,751.72 / $1,751.72
| Professional | | $24.00 | $1,751.72 | $1,751.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,277.56 / $3,277.56 / $3,277.56
| Professional | | $3,277.56 | $3,277.56 | $3,277.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.67 / $783.67 / $783.67
| Professional | | $783.67 | $783.67 | $783.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.72 / $1,751.72 / $1,751.72
| Facility | | $1,751.72 | $1,751.72 | $1,751.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,411.21 / $2,411.21 / $2,411.21
| Professional | | $2,411.21 | $2,411.21 | $2,411.21 |