- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $634.70 / $846.27 / $2,031.05
| Facility | | $634.70 | $846.27 | $2,031.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.24 / $626.24 / $905.51
| Professional | | $626.24 | $626.24 | $905.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $550.08 / $550.08 / $2,260.83
| Facility | | $550.08 | $550.08 | $2,260.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.53 / $1,030.53 / $1,234.70
| Professional | | $1,030.53 | $1,030.53 | $1,234.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $626.24 / $846.27 / $1,421.73
| Facility | | $626.24 | $846.27 | $1,421.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.43 / $355.43 / $3,177.94
| Professional | | $355.43 | $355.43 | $3,177.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.43 / $355.43 / $846.27
| Professional | | $355.43 | $355.43 | $846.27 |