- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.78 / $151.72 / $213.36
| Professional | | $100.78 | $151.72 | $213.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.86 / $195.27 / $313.72
| Professional | | $135.86 | $195.27 | $313.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.54 / $238.43 / $438.12
| Professional | | $136.54 | $238.43 | $438.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.35 / $250.06 / $384.10
| Professional | | $163.35 | $250.06 | $384.10 |