- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.32 / $345.78 / $2,102.34
| Facility | | $310.32 | $345.78 | $2,102.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.78 / $345.78 / $354.65
| Professional | | $345.78 | $345.78 | $354.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $443.31 / $443.31 / $606.23
| Professional | | $443.31 | $443.31 | $606.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $805.67 / $1,092.08 / $2,527.65
| Facility | | $805.67 | $1,092.08 | $2,527.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.32 / $443.31 / $549.70
| Facility | | $310.32 | $443.31 | $549.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.19 / $252.86 / $443.31
| Professional | | $186.19 | $252.86 | $443.31 |