- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $758.58 / $1,513.56
| Facility | | $354.81 | $758.58 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $354.81 / $436.52
| Professional | | $302.00 | $354.81 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $724.44 / $1,380.38
| Facility | | $549.54 | $724.44 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $407.38
| Professional | | $371.54 | $371.54 | $407.38 |