- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,050.71 / $1,050.71 / $1,050.71
| Facility | | $1,050.71 | $1,050.71 | $1,050.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.48 / $346.65 / $799.66
| Professional | | $265.48 | $346.65 | $799.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.68 / $373.68 / $373.68
| Professional | | $373.68 | $373.68 | $373.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.79 / $408.32 / $670.85
| Professional | | $323.79 | $408.32 | $670.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.46 / $567.30 / $879.20
| Professional | | $356.46 | $567.30 | $879.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.67 / $583.14 / $1,144.07
| Professional | | $370.67 | $583.14 | $1,144.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.06 / $522.77 / $1,045.63
| Professional | | $364.06 | $522.77 | $1,045.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.81 / $320.17 / $470.65
| Professional | | $266.81 | $320.17 | $470.65 |