- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $467.74 / $1,258.93
| Facility | | $446.68 | $467.74 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $1,174.90
| Professional | | $446.68 | $446.68 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,174.90
| Professional | | $891.25 | $891.25 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $2,818.38 / $2,818.38
| Facility | | $537.03 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |