- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.27 / $501.27 / $501.27
| Facility | | $501.27 | $501.27 | $501.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.52 / $576.22 / $806.98
| Professional | | $497.52 | $576.22 | $806.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.39 / $755.39 / $1,472.46
| Facility | | $755.39 | $755.39 | $1,472.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.42 / $551.42 / $1,289.33
| Professional | | $551.42 | $551.42 | $1,289.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.19 / $1,354.66 / $1,928.92
| Professional | | $1,345.19 | $1,354.66 | $1,928.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.95 / $1,472.46 / $1,472.46
| Professional | | $1,437.95 | $1,472.46 | $1,472.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.61 / $734.59 / $1,472.46
| Professional | | $547.61 | $734.59 | $1,472.46 |