- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,174.90 / $2,344.23
| Facility | | $512.86 | $1,174.90 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $524.81 / $562.34
| Professional | | $512.86 | $524.81 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $776.25 / $1,122.02
| Facility | | $602.56 | $776.25 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $1,000.00
| Professional | | $512.86 | $512.86 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $758.58 / $1,023.29
| Facility | | $512.86 | $758.58 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $1,122.02
| Facility | | $512.86 | $512.86 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $1,318.26
| Professional | | $512.86 | $512.86 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $891.25
| Facility | | $794.33 | $794.33 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $616.60
| Professional | | $512.86 | $512.86 | $616.60 |