- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,595.43 / $2,599.19 / $3,530.58
| Facility | | $1,595.43 | $2,599.19 | $3,530.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.98 / $87.95 / $101.67
| Professional | | $86.98 | $87.95 | $101.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.12 / $123.80 / $169.32
| Professional | | $87.12 | $123.80 | $169.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,725.32 / $3,420.94 / $5,394.43
| Facility | | $2,725.32 | $3,420.94 | $5,394.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.35 / $135.90 / $223.12
| Professional | | $96.35 | $135.90 | $223.12 |