- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $1,348.96
| Facility | | $524.81 | $524.81 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $562.34 / $707.95
| Professional | | $501.19 | $562.34 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,445.44 / $1,698.24
| Professional | | $977.24 | $1,445.44 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $1,071.52
| Professional | | $851.14 | $851.14 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $562.34 / $1,348.96
| Facility | | $446.68 | $562.34 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $891.25 / $1,513.56
| Professional | | $316.23 | $891.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $758.58 / $1,258.93
| Professional | | $316.23 | $758.58 | $1,258.93 |