- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $891.25 / $1,202.26
| Facility | | $316.23 | $891.25 | $1,202.26 |
- 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
- $309.03 / $588.84 / $691.83
| Professional | | $309.03 | $588.84 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $1,047.13 / $1,047.13
| Facility | | $354.81 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,071.52 / $1,071.52
| Professional | | $616.60 | $1,071.52 | $1,071.52 |