- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $693.54 / $786.01 / $1,008.78
| Facility | | $693.54 | $786.01 | $1,008.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.78 / $1,008.78 / $1,008.78
| Professional | | $1,008.78 | $1,008.78 | $1,008.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.22 / $880.26 / $1,050.81
| Professional | | $748.22 | $880.26 | $1,050.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.65 / $1,008.78 / $1,260.98
| Professional | | $840.65 | $1,008.78 | $1,260.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.07 / $1,008.78 / $1,260.98
| Professional | | $353.07 | $1,008.78 | $1,260.98 |