- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $977.24 / $1,096.48
| Facility | | $354.81 | $977.24 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $380.19
| Professional | | $354.81 | $354.81 | $380.19 |
- 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
- $354.81 / $977.24 / $1,380.38
| Facility | | $354.81 | $977.24 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $512.86 / $691.83
| Professional | | $162.18 | $512.86 | $691.83 |
- 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
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $407.38 / $426.58
| Professional | | $371.54 | $407.38 | $426.58 |