- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.56 / $1,163.40 / $2,297.52
| Facility | | $510.56 | $1,163.40 | $2,297.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.76 / $513.85 / $513.85
| Professional | | $508.76 | $513.85 | $513.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.76 / $1,017.52 / $1,348.21
| Facility | | $508.76 | $1,017.52 | $1,348.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.44 / $508.76 / $722.43
| Professional | | $432.44 | $508.76 | $722.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $763.14
| Facility | | $508.76 | $508.76 | $763.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $635.95
| Professional | | $508.76 | $508.76 | $635.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $1,112.19
| Facility | | $508.76 | $508.76 | $1,112.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.80 / $508.76 / $1,333.06
| Professional | | $432.80 | $508.76 | $1,333.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $630.86
| Professional | | $508.76 | $508.76 | $630.86 |