- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $660.69 / $1,288.25
| Facility | | $616.60 | $660.69 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $660.69 / $1,445.44
| Professional | | $501.19 | $660.69 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,288.25 / $1,412.54
| Professional | | $954.99 | $1,288.25 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $524.81
| Professional | | $416.87 | $416.87 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $1,862.09
| Facility | | $616.60 | $616.60 | $1,862.09 |