- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,995.26 / $2,089.30
| Facility | | $1,737.80 | $1,995.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $1,071.52
| Professional | | $851.14 | $851.14 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $2,818.38
| Professional | | $1,659.59 | $1,659.59 | $2,818.38 |