- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $7,244.36
| Facility | | $4,073.80 | $4,073.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.31 / $144.54 / $354.81
| Professional | | $36.31 | $144.54 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.11 / $52.48 / $223.87
| Professional | | $33.11 | $52.48 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.15 / $89.13 / $251.19
| Professional | | $37.15 | $89.13 | $251.19 |