- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $521.10 / $1,061.34 / $1,093.03
| Facility | | $521.10 | $1,061.34 | $1,093.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.10 / $1,093.03 / $1,093.03
| Professional | | $521.10 | $1,093.03 | $1,093.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.94 / $1,056.80 / $1,108.86
| Professional | | $940.94 | $1,056.80 | $1,108.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.63 / $107.63 / $107.63
| Facility | | $107.63 | $107.63 | $107.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.49 / $107.63 / $144.13
| Professional | | $91.49 | $107.63 | $144.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.91 / $180.91 / $493.00
| Professional | | $180.91 | $180.91 | $493.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.21 / $80.72 / $547.15
| Professional | | $63.21 | $80.72 | $547.15 |