- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $532.04 / $1,083.46 / $1,115.80
| Facility | | $532.04 | $1,083.46 | $1,115.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.04 / $1,115.80 / $1,115.80
| Professional | | $532.04 | $1,115.80 | $1,115.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.72 / $1,078.89 / $1,131.97
| Professional | | $963.72 | $1,078.89 | $1,131.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.87 / $109.87 / $109.87
| Facility | | $109.87 | $109.87 | $109.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.39 / $109.87 / $147.10
| Professional | | $93.39 | $109.87 | $147.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.68 / $184.68 / $493.00
| Professional | | $184.68 | $184.68 | $493.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.56 / $129.28 / $297.58
| Professional | | $77.56 | $129.28 | $297.58 |