- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $949.62 / $3,243.94 / $5,069.20
| Facility | | $949.62 | $3,243.94 | $5,069.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.33 / $420.41 / $610.76
| Professional | | $366.33 | $420.41 | $610.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.08 / $488.69 / $775.52
| Professional | | $353.08 | $488.69 | $775.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.05 / $670.49 / $839.38
| Professional | | $509.05 | $670.49 | $839.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,080.00 / $3,912.00 / $7,350.00
| Facility | | $2,080.00 | $3,912.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.29 / $593.33 / $879.73
| Professional | | $352.29 | $593.33 | $879.73 |