- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $560.75 / $971.08 / $2,336.05
| Facility | | $560.75 | $971.08 | $2,336.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.72 / $524.00 / $941.02
| Professional | | $416.72 | $524.00 | $941.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $484.39 / $806.98 / $1,839.41
| Facility | | $484.39 | $806.98 | $1,839.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.60 / $412.60 / $832.92
| Professional | | $412.60 | $412.60 | $832.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.63 / $392.87 / $563.15
| Facility | | $153.63 | $392.87 | $563.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.00 / $2,052.00 / $2,052.00
| Professional | | $2,052.00 | $2,052.00 | $2,052.00 |