- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $556.23 / $823.22 / $1,779.94
| Facility | | $556.23 | $823.22 | $1,779.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.80 / $548.80 / $556.23
| Professional | | $548.80 | $548.80 | $556.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.58 / $903.58 / $1,082.58
| Professional | | $903.58 | $903.58 | $1,082.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $548.80 / $741.64 / $1,245.96
| Facility | | $548.80 | $741.64 | $1,245.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.49 / $311.49 / $1,112.46
| Professional | | $311.49 | $311.49 | $1,112.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.49 / $311.49 / $741.64
| Professional | | $311.49 | $311.49 | $741.64 |