- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $707.95 / $1,380.38
| Facility | | $537.03 | $707.95 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $575.44 / $707.95
| Professional | | $512.86 | $575.44 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,445.44 / $1,737.80
| Professional | | $1,000.00 | $1,445.44 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,000.00
| Professional | | $794.33 | $794.33 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $575.44 / $1,380.38
| Facility | | $457.09 | $575.44 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $758.58 / $1,513.56
| Professional | | $316.23 | $758.58 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $776.25 / $1,288.25
| Professional | | $316.23 | $776.25 | $1,288.25 |