- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,484.55 / $1,484.55 / $1,484.55
| Facility | | $1,484.55 | $1,484.55 | $1,484.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,484.55
| Professional | | $1,427.45 | $1,427.45 | $1,484.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $35.20
| Facility | | $0.02 | $0.02 | $35.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.65 / $1,427.45 / $1,427.45
| Facility | | $1,346.65 | $1,427.45 | $1,427.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Professional | | $1,427.45 | $1,427.45 | $1,427.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Professional | | $1,427.45 | $1,427.45 | $1,427.45 |