- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $392.06 / $1,101.89 / $1,484.81
| Facility | | $392.06 | $1,101.89 | $1,484.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.06 / $392.06 / $392.06
| Professional | | $392.06 | $392.06 | $392.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.75 / $597.78 / $1,010.79
| Professional | | $390.75 | $597.78 | $1,010.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $369.87 / $369.87 / $392.06
| Facility | | $369.87 | $369.87 | $392.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.25 / $333.25 / $392.06
| Professional | | $333.25 | $333.25 | $392.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.77 / $392.06 / $635.44
| Professional | | $356.77 | $392.06 | $635.44 |