- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,066.30 / $1,066.30 / $1,472.51
| Facility | | $1,066.30 | $1,066.30 | $1,472.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.76 / $820.88 / $1,066.30
| Professional | | $507.76 | $820.88 | $1,066.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.65 / $1,269.41 / $1,269.41
| Professional | | $761.65 | $1,269.41 | $1,269.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $550.08 / $1,091.58 / $1,586.45
| Facility | | $550.08 | $1,091.58 | $1,586.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.51 / $746.57 / $1,272.20
| Professional | | $345.51 | $746.57 | $1,272.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $761.64 / $761.64 / $761.64
| Facility | | $761.64 | $761.64 | $761.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.43 / $507.76 / $846.27
| Professional | | $355.43 | $507.76 | $846.27 |