- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $740.84 / $740.84 / $740.84
| Facility | | $740.84 | $740.84 | $740.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.69 / $603.94 / $823.18
| Professional | | $527.69 | $603.94 | $823.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.74 / $1,053.86 / $1,164.72
| Facility | | $867.74 | $1,053.86 | $1,164.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.85 / $705.71 / $705.71
| Professional | | $599.85 | $705.71 | $705.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,224.34 / $2,224.34 / $2,224.34
| Facility | | $2,224.34 | $2,224.34 | $2,224.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.80 / $665.10 / $1,455.58
| Professional | | $553.80 | $665.10 | $1,455.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,113.09 / $1,113.09 / $1,113.09
| Facility | | $1,113.09 | $1,113.09 | $1,113.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.33 / $641.36 / $910.23
| Professional | | $461.33 | $641.36 | $910.23 |