- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $392.59 / $718.19 / $1,017.93
| Facility | | $392.59 | $718.19 | $1,017.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.81 / $453.92 / $515.80
| Professional | | $316.81 | $453.92 | $515.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.28 / $797.28 / $797.28
| Professional | | $797.28 | $797.28 | $797.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,555.30 / $1,555.30 / $1,555.30
| Facility | | $1,555.30 | $1,555.30 | $1,555.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.28 / $797.28 / $797.28
| Professional | | $797.28 | $797.28 | $797.28 |