- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $707.95 / $1,348.96
| Facility | | $524.81 | $707.95 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $676.08 / $891.25
| Professional | | $524.81 | $676.08 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,513.56 / $1,698.24
| Professional | | $1,096.48 | $1,513.56 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $1,096.48
| Professional | | $870.96 | $870.96 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $891.25 / $3,548.13
| Facility | | $524.81 | $891.25 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $380.19 / $1,288.25
| Professional | | $316.23 | $380.19 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $758.58 / $1,096.48
| Professional | | $316.23 | $758.58 | $1,096.48 |