- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,859.17 / $7,885.35 / $12,523.20
| Facility | | $3,859.17 | $7,885.35 | $12,523.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.17 / $4,547.70 / $9,251.04
| Professional | | $3,859.17 | $4,547.70 | $9,251.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.03 / $0.03
| Facility | | $0.02 | $0.03 | $0.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.81 / $1,949.81 / $1,949.81
| Facility | | $1,949.81 | $1,949.81 | $1,949.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $1,326.50
| Professional | | $1,326.50 | $1,326.50 | $1,326.50 |