- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $887.63 / $3,243.94 / $3,955.04
| Facility | | $887.63 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.52 / $330.03 / $453.40
| Professional | | $235.52 | $330.03 | $453.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.42 / $377.02 / $604.53
| Professional | | $268.42 | $377.02 | $604.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.12 / $522.10 / $882.84
| Professional | | $307.12 | $522.10 | $882.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.31 / $550.63 / $805.33
| Professional | | $331.31 | $550.63 | $805.33 |