- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $530.55 / $1,032.19 / $1,784.84
| Facility | | $530.55 | $1,032.19 | $1,784.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $844.84 / $1,032.19
| Professional | | $836.47 | $844.84 | $1,032.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.40 / $788.40 / $788.40
| Professional | | $788.40 | $788.40 | $788.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,032.19 / $1,052.83 / $1,383.13
| Facility | | $1,032.19 | $1,052.83 | $1,383.13 |