- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $604.66 / $604.66 / $604.66
| Facility | | $604.66 | $604.66 | $604.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.07 / $640.08 / $880.98
| Professional | | $512.07 | $640.08 | $880.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.29 / $619.65 / $1,671.02
| Facility | | $368.29 | $619.65 | $1,671.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.47 / $681.26 / $2,343.00
| Professional | | $368.47 | $681.26 | $2,343.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.88 / $566.90 / $859.20
| Professional | | $352.88 | $566.90 | $859.20 |