- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $553.48 / $771.78 / $1,355.50
| Facility | | $553.48 | $771.78 | $1,355.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.13 / $511.72 / $547.54
| Professional | | $486.13 | $511.72 | $547.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.37 / $1,039.21 / $1,535.15
| Professional | | $831.37 | $1,039.21 | $1,535.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.00 / $655.00 / $655.00
| Facility | | $655.00 | $655.00 | $655.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.00 / $655.00 / $818.74
| Professional | | $655.00 | $655.00 | $818.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.56 / $409.37 / $682.29
| Professional | | $286.56 | $409.37 | $682.29 |