- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.84 / $1,202.84 / $1,202.84
| Facility | | $1,202.84 | $1,202.84 | $1,202.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.84 / $1,202.84 / $1,232.55
| Professional | | $1,202.84 | $1,202.84 | $1,232.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.20 / $0.32 / $0.51
| Facility | | $0.20 | $0.32 | $0.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $1,670.63
| Professional | | $1,262.25 | $1,262.25 | $1,670.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.00 / $6,558.75 / $6,558.75
| Facility | | $1,485.00 | $6,558.75 | $6,558.75 |