- 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
- $101.05 / $127.27 / $172.84
| Professional | | $101.05 | $127.27 | $172.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.97 / $154.24 / $203.29
| Professional | | $107.97 | $154.24 | $203.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.16 / $184.53 / $254.23
| Professional | | $109.16 | $184.53 | $254.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.22 / $1,183.00 / $4,915.00
| Facility | | $510.22 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.12 / $176.23 / $271.61
| Professional | | $128.12 | $176.23 | $271.61 |