- 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
- $120.97 / $156.41 / $219.60
| Professional | | $120.97 | $156.41 | $219.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.64 / $156.68 / $280.95
| Professional | | $124.64 | $156.68 | $280.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.50 / $218.40 / $293.77
| Professional | | $162.50 | $218.40 | $293.77 |
- 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
- $116.81 / $183.23 / $315.52
| Professional | | $116.81 | $183.23 | $315.52 |