- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $1,737.80
| Facility | | $309.03 | $309.03 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $537.03 / $1,174.90
| Professional | | $389.05 | $537.03 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $1,819.70
| Professional | | $676.08 | $676.08 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $660.69 / $977.24
| Professional | | $407.38 | $660.69 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $660.69 / $831.76
| Professional | | $501.19 | $660.69 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $616.60 / $1,174.90
| Professional | | $512.86 | $616.60 | $1,174.90 |