- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,421.23 / $1,421.23 / $1,531.50
| Facility | | $1,421.23 | $1,421.23 | $1,531.50 |
- 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
- $522.47 / $655.83 / $1,710.97
| Facility | | $522.47 | $655.83 | $1,710.97 |
- 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
- $520.71 / $520.71 / $520.71
| Facility | | $520.71 | $520.71 | $520.71 |
- 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
- $520.71 / $520.71 / $630.58
| Professional | | $520.71 | $520.71 | $630.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,421.23 / $1,421.23 / $1,531.50
| Facility | | $1,421.23 | $1,421.23 | $1,531.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $1,531.50
| Professional | | $520.71 | $520.71 | $1,531.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.50 / $510.50 / $740.23
| Professional | | $510.50 | $510.50 | $740.23 |