- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $690.17 / $1,422.34 / $1,898.46
| Facility | | $690.17 | $1,422.34 | $1,898.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.18 / $690.18 / $967.29
| Professional | | $690.18 | $690.18 | $967.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.71 / $627.71 / $1,035.72
| Professional | | $627.71 | $627.71 | $1,035.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $734.67 / $734.67 / $734.67
| Facility | | $734.67 | $734.67 | $734.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.52 / $240.52 / $240.52
| Professional | | $240.52 | $240.52 | $240.52 |