- 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
- $107.98 / $146.60 / $196.44
| Professional | | $107.98 | $146.60 | $196.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.07 / $173.82 / $272.49
| Professional | | $122.07 | $173.82 | $272.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.48 / $206.60 / $393.04
| Professional | | $127.48 | $206.60 | $393.04 |
- 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
- $150.51 / $236.70 / $360.80
| Professional | | $150.51 | $236.70 | $360.80 |