- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $415.04 / $997.19 / $1,146.76
| Facility | | $415.04 | $997.19 | $1,146.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.04 / $415.04 / $518.79
| Professional | | $415.04 | $415.04 | $518.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.98 / $440.98 / $440.98
| Professional | | $440.98 | $440.98 | $440.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $395.27 / $652.20 / $751.01
| Facility | | $395.27 | $652.20 | $751.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.69 / $1,754.69 / $1,754.69
| Professional | | $1,754.69 | $1,754.69 | $1,754.69 |