- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,461.23 / $2,489.52 / $2,718.05
| Facility | | $2,461.23 | $2,489.52 | $2,718.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.10 / $1,145.06 / $1,145.06
| Professional | | $751.10 | $1,145.06 | $1,145.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.86 / $520.86 / $520.86
| Professional | | $520.86 | $520.86 | $520.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $751.10 / $1,145.06 / $1,935.15
| Facility | | $751.10 | $1,145.06 | $1,935.15 |