- 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
- $108.73 / $142.60 / $192.01
| Professional | | $108.73 | $142.60 | $192.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.07 / $172.40 / $266.27
| Professional | | $121.07 | $172.40 | $266.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.40 / $201.75 / $383.61
| Professional | | $126.40 | $201.75 | $383.61 |
- 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
- $147.47 / $209.07 / $352.12
| Professional | | $147.47 | $209.07 | $352.12 |