- 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
- $106.18 / $124.35 / $129.71
| Professional | | $106.18 | $124.35 | $129.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.97 / $139.96 / $189.04
| Professional | | $118.97 | $139.96 | $189.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.43 / $192.06 / $264.97
| Professional | | $110.43 | $192.06 | $264.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,602.00
| Facility | | $1,069.00 | $1,788.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.52 / $160.54 / $247.33
| Professional | | $103.52 | $160.54 | $247.33 |