- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $628.20 / $628.20 / $3,706.14
| Facility | | $628.20 | $628.20 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.56 / $352.02 / $502.09
| Professional | | $281.56 | $352.02 | $502.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.39 / $381.54 / $643.88
| Professional | | $300.39 | $381.54 | $643.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.35 / $535.39 / $689.25
| Professional | | $411.35 | $535.39 | $689.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.24 / $1,401.00 / $4,915.00
| Facility | | $503.24 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.98 / $486.26 / $751.67
| Professional | | $280.98 | $486.26 | $751.67 |