- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $530.85 / $530.85 / $1,365.05
| Facility | | $530.85 | $530.85 | $1,365.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.85 / $712.86 / $712.86
| Professional | | $530.85 | $712.86 | $712.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.52 / $1,528.10 / $1,706.31
| Professional | | $1,141.52 | $1,528.10 | $1,706.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.43 / $871.43 / $1,279.30
| Professional | | $871.43 | $871.43 | $1,279.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.02 / $576.35 / $1,365.05
| Facility | | $455.02 | $576.35 | $1,365.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.76 / $910.03 / $1,516.72
| Professional | | $386.76 | $910.03 | $1,516.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.51 / $773.53 / $1,289.21
| Professional | | $318.51 | $773.53 | $1,289.21 |