- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,601.13 / $3,033.72 / $3,530.58
| Facility | | $1,601.13 | $3,033.72 | $3,530.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.95 / $65.38 / $141.85
| Professional | | $52.95 | $65.38 | $141.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.86 / $106.99 / $197.09
| Professional | | $58.86 | $106.99 | $197.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,935.99 / $3,420.94 / $5,113.20
| Facility | | $1,935.99 | $3,420.94 | $5,113.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.63 / $146.22 / $287.55
| Professional | | $114.63 | $146.22 | $287.55 |