- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.20 / $935.50 / $1,037.74
| Facility | | $511.20 | $935.50 | $1,037.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.85 / $403.85 / $403.85
| Professional | | $403.85 | $403.85 | $403.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $332.28 / $332.28 / $348.89
| Facility | | $332.28 | $332.28 | $348.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.29 / $587.29 / $734.11
| Professional | | $587.29 | $587.29 | $734.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.70 / $255.60 / $872.60
| Professional | | $214.70 | $255.60 | $872.60 |