- 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
- $85.35 / $116.77 / $138.56
| Professional | | $85.35 | $116.77 | $138.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.14 / $133.10 / $228.97
| Professional | | $113.14 | $133.10 | $228.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.15 / $161.05 / $250.44
| Professional | | $105.15 | $161.05 | $250.44 |
- 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
- $103.21 / $152.69 / $235.28
| Professional | | $103.21 | $152.69 | $235.28 |