- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $381.36 / $1,072.10 / $1,444.68
| Facility | | $381.36 | $1,072.10 | $1,444.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.36 / $381.36 / $381.36
| Professional | | $381.36 | $381.36 | $381.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.18 / $575.14 / $972.51
| Professional | | $380.18 | $575.14 | $972.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $359.77 / $359.77 / $381.36
| Facility | | $359.77 | $359.77 | $381.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.16 / $324.16 / $381.36
| Professional | | $324.16 | $324.16 | $381.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.04 / $381.36 / $618.10
| Professional | | $347.04 | $381.36 | $618.10 |