- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $719.73 / $719.73 / $719.73
| Facility | | $719.73 | $719.73 | $719.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.73 / $1,083.81 / $1,163.85
| Professional | | $719.73 | $1,083.81 | $1,163.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.66 / $171.36 / $172.65
| Professional | | $145.66 | $171.36 | $172.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,354.64 / $1,368.19 / $1,720.39
| Professional | | $1,354.64 | $1,368.19 | $1,720.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $719.73 / $1,691.40 / $7,207.17
| Facility | | $719.73 | $1,691.40 | $7,207.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.84 / $1,288.81 / $1,850.27
| Professional | | $431.84 | $1,288.81 | $1,850.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.84 / $563.79 / $1,747.92
| Professional | | $431.84 | $563.79 | $1,747.92 |