- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $567.85 / $886.27 / $2,132.04
| Facility | | $567.85 | $886.27 | $2,132.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.32 / $833.03 / $1,190.55
| Professional | | $494.32 | $833.03 | $1,190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $492.09 / $808.78 / $1,678.78
| Facility | | $492.09 | $808.78 | $1,678.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $444.09 / $730.94 / $1,007.12
| Professional | | $444.09 | $730.94 | $1,007.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.88 / $377.64 / $685.54
| Facility | | $351.88 | $377.64 | $685.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,550.73 / $2,550.73 / $2,550.73
| Professional | | $2,550.73 | $2,550.73 | $2,550.73 |