- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $891.25 / $1,445.44
| Facility | | $316.23 | $891.25 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $478.63
| Professional | | $316.23 | $316.23 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $870.96 / $1,023.29
| Professional | | $691.83 | $870.96 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $1,230.27 / $1,230.27
| Facility | | $354.81 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $1,778.28
| Professional | | $1,202.26 | $1,778.28 | $1,778.28 |