- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $409.70 / $1,487.34 / $1,487.35
| Facility | | $409.70 | $1,487.34 | $1,487.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.07 / $834.64 / $1,487.35
| Professional | | $704.07 | $834.64 | $1,487.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.82 / $922.82 / $922.82
| Professional | | $922.82 | $922.82 | $922.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $906.54 / $906.54 / $1,560.91
| Facility | | $906.54 | $906.54 | $1,560.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.77 / $906.54 / $1,366.79
| Professional | | $661.77 | $906.54 | $1,366.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.18 / $630.26 / $1,015.86
| Professional | | $420.18 | $630.26 | $1,015.86 |