- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.40 / $921.22 / $1,021.90
| Facility | | $503.40 | $921.22 | $1,021.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.69 / $397.69 / $397.69
| Professional | | $397.69 | $397.69 | $397.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.40 / $503.40 / $503.40
| Facility | | $503.40 | $503.40 | $503.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.40 / $503.40 / $503.40
| Professional | | $503.40 | $503.40 | $503.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.20 / $343.57 / $381.85
| Facility | | $327.20 | $343.57 | $381.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.00 / $525.00 / $656.25
| Professional | | $525.00 | $525.00 | $656.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.43 / $276.87 / $755.10
| Professional | | $211.43 | $276.87 | $755.10 |