- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,150.65 / $1,543.03 / $3,955.04
| Facility | | $1,150.65 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.88 / $328.87 / $410.83
| Professional | | $259.88 | $328.87 | $410.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.91 / $450.63 / $624.26
| Professional | | $307.91 | $450.63 | $624.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.56 / $522.16 / $916.46
| Professional | | $376.56 | $522.16 | $916.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,284.14 / $4,915.00
| Facility | | $540.00 | $1,284.14 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.51 / $637.39 / $982.61
| Professional | | $390.51 | $637.39 | $982.61 |