- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $870.96 / $1,698.24
| Facility | | $295.12 | $870.96 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $323.59 / $645.65
| Professional | | $302.00 | $323.59 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $309.03 / $602.56
| Professional | | $269.15 | $309.03 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $323.59
| Professional | | $295.12 | $295.12 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $363.08 / $363.08
| Professional | | $338.84 | $363.08 | $363.08 |