- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.41 / $777.62 / $1,681.34
| Facility | | $525.41 | $777.62 | $1,681.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.41 / $518.41 / $525.41
| Professional | | $518.41 | $518.41 | $525.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.23 / $853.23 / $1,022.27
| Professional | | $853.23 | $853.23 | $1,022.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $518.41 / $700.56 / $1,176.94
| Facility | | $518.41 | $700.56 | $1,176.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.24 / $294.24 / $1,050.83
| Professional | | $294.24 | $294.24 | $1,050.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.24 / $294.24 / $448.36
| Professional | | $294.24 | $294.24 | $448.36 |