- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $742.27 / $742.27 / $1,577.32
| Facility | | $742.27 | $742.27 | $1,577.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.24 / $601.24 / $601.24
| Professional | | $601.24 | $601.24 | $601.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.91 / $326.60 / $1,660.69
| Professional | | $296.91 | $326.60 | $1,660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.27 / $742.27 / $749.69
| Professional | | $742.27 | $742.27 | $749.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $742.27 / $742.27 / $1,202.48
| Facility | | $742.27 | $742.27 | $1,202.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.24 / $601.24 / $742.27
| Professional | | $601.24 | $601.24 | $742.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.36 / $445.36 / $1,113.41
| Professional | | $445.36 | $445.36 | $1,113.41 |