- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $523.87 / $523.87 / $1,347.10
| Facility | | $523.87 | $523.87 | $1,347.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.87 / $523.87 / $523.87
| Professional | | $523.87 | $523.87 | $523.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.52 / $1,508.01 / $1,683.88
| Professional | | $1,126.52 | $1,508.01 | $1,683.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.28 / $860.28 / $1,262.93
| Professional | | $860.28 | $860.28 | $1,262.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $449.03 / $568.78 / $1,347.10
| Facility | | $449.03 | $568.78 | $1,347.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.68 / $898.07 / $1,496.78
| Professional | | $381.68 | $898.07 | $1,496.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.32 / $763.36 / $1,272.26
| Professional | | $314.32 | $763.36 | $1,272.26 |