- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $725.40 / $824.32 / $1,300.38
| Facility | | $725.40 | $824.32 | $1,300.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.79 / $1,048.38 / $1,191.33
| Professional | | $420.79 | $1,048.38 | $1,191.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.00 / $1,663.45 / $1,663.45
| Professional | | $396.00 | $1,663.45 | $1,663.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $70.00 / $70.00
| Professional | | $70.00 | $70.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.65 / $1,078.65 / $1,078.65
| Facility | | $1,078.65 | $1,078.65 | $1,078.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.66 / $1,663.45 / $1,663.45
| Professional | | $901.66 | $1,663.45 | $1,663.45 |