- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $281.84 / $602.56
| Professional | | $229.09 | $281.84 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $588.84 / $707.95
| Professional | | $478.63 | $588.84 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $407.38 / $575.44
| Professional | | $331.13 | $407.38 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,951.21 / $10,471.29
| Facility | | $2,630.27 | $2,951.21 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $467.74 / $933.25
| Professional | | $302.00 | $467.74 | $933.25 |