- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $543.47 / $543.47 / $563.28
| Facility | | $543.47 | $543.47 | $563.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.47 / $543.47 / $549.22
| Professional | | $543.47 | $543.47 | $549.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.00 / $2,301.00 / $2,301.00
| Professional | | $1,401.00 | $2,301.00 | $2,301.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.78 / $746.24 / $1,909.61
| Professional | | $726.78 | $746.24 | $1,909.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.76 / $909.60 / $1,641.36
| Professional | | $571.76 | $909.60 | $1,641.36 |