- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $868.52 / $868.52 / $868.52
| Facility | | $868.52 | $868.52 | $868.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.91 / $793.31 / $1,466.47
| Professional | | $602.91 | $793.31 | $1,466.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.49 / $784.86 / $1,322.06
| Professional | | $604.49 | $784.86 | $1,322.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.53 / $766.47 / $1,255.78
| Professional | | $587.53 | $766.47 | $1,255.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $747.28 / $1,187.59
| Professional | | $5.00 | $747.28 | $1,187.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $791.73 / $1,187.59
| Professional | | $5.00 | $791.73 | $1,187.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.40 / $750.30 / $1,228.42
| Professional | | $584.40 | $750.30 | $1,228.42 |