- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $1,230.27
| Facility | | $478.63 | $478.63 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $524.81 / $645.65
| Professional | | $457.09 | $524.81 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $1,548.82
| Professional | | $1,000.00 | $1,318.26 | $1,548.82 |
- 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
- $416.87 / $524.81 / $1,230.27
| Facility | | $416.87 | $524.81 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $812.83 / $1,380.38
| Professional | | $288.40 | $812.83 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $707.95 / $1,174.90
| Professional | | $288.40 | $707.95 | $1,174.90 |