- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $798.37 / $1,361.25 / $2,253.42
| Facility | | $798.37 | $1,361.25 | $2,253.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.32 / $798.38 / $798.38
| Professional | | $410.32 | $798.38 | $798.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $497.70 / $603.98 / $812.55
| Facility | | $497.70 | $603.98 | $812.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.00 / $495.00 / $584.10
| Professional | | $495.00 | $495.00 | $584.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.51 / $291.51 / $509.60
| Professional | | $291.51 | $291.51 | $509.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.40 / $440.40 / $440.40
| Professional | | $440.40 | $440.40 | $440.40 |