- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.04 / $585.04 / $1,023.82
| Facility | | $585.04 | $585.04 | $1,023.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.04 / $585.04 / $603.50
| Professional | | $585.04 | $585.04 | $603.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.65 / $587.65 / $587.65
| Professional | | $587.65 | $587.65 | $587.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.87 / $603.87 / $603.87
| Facility | | $603.87 | $603.87 | $603.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.73 / $1,000.73 / $1,000.73
| Professional | | $1,000.73 | $1,000.73 | $1,000.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.62 / $1,385.62 / $1,385.62
| Professional | | $1,385.62 | $1,385.62 | $1,385.62 |