- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,888.71 / $7,652.51 / $13,582.84
| Facility | | $2,888.71 | $7,652.51 | $13,582.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.17 / $5,231.70 / $9,251.04
| Professional | | $3,859.17 | $5,231.70 | $9,251.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.97 / $1.00 / $1.00
| Facility | | $0.97 | $1.00 | $1.00 |
- 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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $983.91 / $2,572.71 / $4,024.24
| Facility | | $983.91 | $2,572.71 | $4,024.24 |