- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.08 / $239.32 / $6,867.19
| Facility | | $166.08 | $239.32 | $6,867.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $117.15 / $157.28
| Professional | | $108.47 | $117.15 | $157.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.68 / $140.47 / $824.24
| Facility | | $125.68 | $140.47 | $824.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.14 / $118.14 / $118.14
| Professional | | $118.14 | $118.14 | $118.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $108.47 / $647.00
| Facility | | $102.33 | $108.47 | $647.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $108.47
| Professional | | $108.47 | $108.47 | $108.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.28 / $161.74 / $343.94
| Facility | | $109.28 | $161.74 | $343.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.28 / $121.65 / $1,698.40
| Professional | | $109.28 | $121.65 | $1,698.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $114.98 / $135.69
| Professional | | $108.47 | $114.98 | $135.69 |