- 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
- $62.17 / $90.14 / $108.69
| Professional | | $62.17 | $90.14 | $108.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.59 / $102.48 / $165.56
| Professional | | $62.59 | $102.48 | $165.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.48 / $142.63 / $245.83
| Professional | | $86.48 | $142.63 | $245.83 |
- 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
- $84.43 / $136.24 / $229.50
| Professional | | $84.43 | $136.24 | $229.50 |