- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $592.39 / $660.09 / $4,013.35
| Facility | | $592.39 | $660.09 | $4,013.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.09 / $660.09 / $677.02
| Professional | | $660.09 | $660.09 | $677.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.27 / $846.27 / $1,157.27
| Professional | | $846.27 | $846.27 | $1,157.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,538.02 / $2,084.80 / $4,825.30
| Facility | | $1,538.02 | $2,084.80 | $4,825.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.09 / $846.27 / $1,069.34
| Facility | | $660.09 | $846.27 | $1,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.43 / $482.70 / $846.27
| Professional | | $355.43 | $482.70 | $846.27 |