- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $745.23 / $870.86 / $1,335.92
| Facility | | $745.23 | $870.86 | $1,335.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.72 / $702.42 / $1,024.45
| Professional | | $542.72 | $702.42 | $1,024.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.86 / $1,522.86 / $1,522.86
| Professional | | $1,522.86 | $1,522.86 | $1,522.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,251.36 / $1,251.36 / $1,251.36
| Facility | | $1,251.36 | $1,251.36 | $1,251.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.27 / $1,522.86 / $1,522.86
| Professional | | $513.27 | $1,522.86 | $1,522.86 |