- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $784.52 / $784.52 / $784.52
| Facility | | $784.52 | $784.52 | $784.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.16 / $764.88 / $784.52
| Professional | | $712.16 | $764.88 | $784.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.21 / $1,192.06 / $1,221.71
| Professional | | $1,008.21 | $1,192.06 | $1,221.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.63 / $1,069.21 / $1,344.45
| Professional | | $1,058.63 | $1,069.21 | $1,344.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $374.87 / $784.52 / $4,278.92
| Facility | | $374.87 | $784.52 | $4,278.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.87 / $605.20 / $859.16
| Professional | | $371.87 | $605.20 | $859.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.98 / $605.20 / $959.84
| Professional | | $268.98 | $605.20 | $959.84 |