- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $514.04 / $1,180.03 / $2,361.19
| Facility | | $514.04 | $1,180.03 | $2,361.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.96 / $514.04 / $519.52
| Professional | | $508.96 | $514.04 | $519.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.96 / $1,017.92 / $1,348.74
| Facility | | $508.96 | $1,017.92 | $1,348.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.61 / $508.96 / $722.72
| Professional | | $432.61 | $508.96 | $722.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.96 / $559.86 / $763.44
| Facility | | $508.96 | $559.86 | $763.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $559.86 / $559.86 / $559.86
| Professional | | $559.86 | $559.86 | $559.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.96 / $508.96 / $508.96
| Facility | | $508.96 | $508.96 | $508.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.01 / $508.96 / $1,352.12
| Professional | | $457.01 | $508.96 | $1,352.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.96 / $508.96 / $631.11
| Professional | | $508.96 | $508.96 | $631.11 |