- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $849.58 / $849.58 / $1,339.25
| Facility | | $849.58 | $849.58 | $1,339.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.73 / $849.58 / $1,249.25
| Professional | | $697.73 | $849.58 | $1,249.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.73 / $1,080.52 / $1,834.12
| Professional | | $781.73 | $1,080.52 | $1,834.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.35 / $1,316.47 / $1,897.91
| Professional | | $987.35 | $1,316.47 | $1,897.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.20 / $946.64 / $1,642.39
| Professional | | $649.20 | $946.64 | $1,642.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.04 / $832.59 / $1,514.47
| Professional | | $626.04 | $832.59 | $1,514.47 |