- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $890.93 / $890.93 / $1,069.11
| Facility | | $890.93 | $890.93 | $1,069.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.56 / $751.56 / $890.93
| Professional | | $751.56 | $751.56 | $890.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.01 / $8.01 / $8.01
| Professional | | $8.01 | $8.01 | $8.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.77 / $477.77 / $477.77
| Professional | | $477.77 | $477.77 | $477.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.65 / $2,024.61 / $3,328.36
| Professional | | $1,352.65 | $2,024.61 | $3,328.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.46 / $2,371.46 / $2,371.46
| Professional | | $2,371.46 | $2,371.46 | $2,371.46 |