- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $658.03 / $1,235.52 / $1,909.13
| Facility | | $658.03 | $1,235.52 | $1,909.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.43 / $520.17 / $639.76
| Professional | | $448.43 | $520.17 | $639.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $609.87 / $609.87 / $609.87
| Professional | | $609.87 | $609.87 | $609.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $528.54 / $979.37 / $1,355.44
| Facility | | $528.54 | $979.37 | $1,355.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.33 / $597.91 / $863.68
| Facility | | $478.33 | $597.91 | $863.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.12 / $358.75 / $2,989.55
| Professional | | $251.12 | $358.75 | $2,989.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.75 / $358.75 / $597.91
| Facility | | $358.75 | $358.75 | $597.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.12 / $358.75 / $896.87
| Professional | | $251.12 | $358.75 | $896.87 |