- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,905.46 / $3,019.95
| Facility | | $1,096.48 | $1,905.46 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.31 / $199.53 / $354.81
| Professional | | $36.31 | $199.53 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,754.23 / $3,715.35
| Facility | | $2,344.23 | $2,754.23 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $6,309.57 / $11,220.18
| Facility | | $2,511.89 | $6,309.57 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $54.95 / $87.10
| Professional | | $38.90 | $54.95 | $87.10 |