- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $818.74 / $818.74 / $2,894.54
| Facility | | $818.74 | $818.74 | $2,894.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.46 / $827.01 / $827.01
| Professional | | $508.46 | $827.01 | $827.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Professional | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,182.61 / $1,182.61 / $1,182.61
| Facility | | $1,182.61 | $1,182.61 | $1,182.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $857.64 / $857.64 / $1,347.72
| Facility | | $857.64 | $857.64 | $1,347.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $857.64 / $1,182.61 / $2,021.58
| Facility | | $857.64 | $1,182.61 | $2,021.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Professional | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.50 / $765.75 / $1,029.78
| Professional | | $510.50 | $765.75 | $1,029.78 |