- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $977.24 / $1,096.48
| Facility | | $616.60 | $977.24 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $602.56 / $616.60
| Professional | | $501.19 | $602.56 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $812.83 / $2,691.53
| Facility | | $616.60 | $812.83 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $602.56 / $1,621.81
| Professional | | $512.86 | $602.56 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Facility | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Professional | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $263.03 / $263.03
| Professional | | $151.36 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $676.08 / $691.83
| Professional | | $645.65 | $676.08 | $691.83 |