- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $430.07 / $430.08 / $1,175.16
| Facility | | $430.07 | $430.08 | $1,175.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.08 / $597.36 / $838.38
| Professional | | $430.08 | $597.36 | $838.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $906.54 / $906.54 / $1,263.33
| Facility | | $906.54 | $906.54 | $1,263.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.77 / $661.77 / $1,106.22
| Professional | | $661.77 | $661.77 | $1,106.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.15 / $1,162.26 / $1,654.96
| Professional | | $1,154.15 | $1,162.26 | $1,654.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.46 / $1,263.33 / $1,263.33
| Professional | | $1,202.46 | $1,263.33 | $1,263.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.08 / $630.26 / $1,159.80
| Professional | | $569.08 | $630.26 | $1,159.80 |