- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.80 / $681.80 / $1,032.25
| Facility | | $681.80 | $681.80 | $1,032.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.74 / $687.08 / $1,467.45
| Professional | | $601.74 | $687.08 | $1,467.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.66 / $1,066.08 / $1,833.05
| Professional | | $631.66 | $1,066.08 | $1,833.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.68 / $1,102.41 / $2,945.88
| Professional | | $841.68 | $1,102.41 | $2,945.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.06 / $1,012.55 / $1,833.28
| Professional | | $791.06 | $1,012.55 | $1,833.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.13 / $837.53 / $1,483.43
| Professional | | $576.13 | $837.53 | $1,483.43 |