- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $997.19 / $1,142.24 / $1,269.16
| Facility | | $997.19 | $1,142.24 | $1,269.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.54 / $906.54 / $906.54
| Professional | | $906.54 | $906.54 | $906.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.32 / $510.39 / $534.47
| Professional | | $486.32 | $510.39 | $534.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $906.54 / $970.00 / $1,840.28
| Facility | | $906.54 | $970.00 | $1,840.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.29 / $224.52 / $336.05
| Professional | | $163.29 | $224.52 | $336.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.29 / $224.52 / $336.05
| Professional | | $163.29 | $224.52 | $336.05 |