- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.40 / $140.33 / $166.85
| Professional | | $107.40 | $140.33 | $166.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.46 / $155.84 / $260.26
| Professional | | $132.46 | $155.84 | $260.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.63 / $188.68 / $274.36
| Professional | | $133.63 | $188.68 | $274.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.06 / $190.18 / $291.80
| Professional | | $116.06 | $190.18 | $291.80 |