- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $406.34 / $406.34 / $1,064.34
| Facility | | $406.34 | $406.34 | $1,064.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.43 / $427.86 / $1,064.34
| Professional | | $400.43 | $427.86 | $1,064.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.20 / $531.85 / $954.19
| Professional | | $382.20 | $531.85 | $954.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.69 / $706.32 / $1,124.15
| Professional | | $394.69 | $706.32 | $1,124.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.55 / $642.25 / $1,375.61
| Professional | | $527.55 | $642.25 | $1,375.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.29 / $670.12 / $977.36
| Professional | | $440.29 | $670.12 | $977.36 |