- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,230.27 / $1,380.38
| Facility | | $676.08 | $1,230.27 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $549.54 / $1,230.27
| Professional | | $512.86 | $549.54 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $537.03 / $537.03
| Facility | | $537.03 | $537.03 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $537.03 / $537.03
| Professional | | $537.03 | $537.03 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $512.86 / $1,174.90
| Facility | | $436.52 | $512.86 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $602.56 / $1,148.15
| Professional | | $288.40 | $602.56 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $676.08 / $812.83
| Facility | | $602.56 | $676.08 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $407.38 / $1,737.80
| Professional | | $281.84 | $407.38 | $1,737.80 |