- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.07 / $1,600.00 / $3,667.00
| Facility | | $402.07 | $1,600.00 | $3,667.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $418.35 / $475.00
| Professional | | $318.75 | $418.35 | $475.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $611.37 / $1,015.71 / $1,290.98
| Facility | | $611.37 | $1,015.71 | $1,290.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.24 / $868.25 / $1,882.81
| Facility | | $836.24 | $868.25 | $1,882.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.68 / $305.50 / $305.50
| Professional | | $259.68 | $305.50 | $305.50 |