- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $528.82 / $528.82 / $528.82
| Facility | | $528.82 | $528.82 | $528.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.58 / $437.37 / $510.27
| Facility | | $291.58 | $437.37 | $510.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.37 / $676.04 / $676.04
| Professional | | $437.37 | $676.04 | $676.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,869.02 / $2,225.03 / $4,072.40
| Facility | | $1,869.02 | $2,225.03 | $4,072.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.85 / $1,621.85 / $1,621.85
| Facility | | $1,621.85 | $1,621.85 | $1,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.25 / $445.06 / $735.22
| Professional | | $268.25 | $445.06 | $735.22 |