- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $363.08 / $1,202.26
| Facility | | $288.40 | $363.08 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $295.12 / $363.08
| Professional | | $288.40 | $295.12 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $436.52 / $831.76
| Facility | | $316.23 | $436.52 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $323.59 / $575.44
| Professional | | $288.40 | $323.59 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $436.52 / $891.25
| Facility | | $263.03 | $436.52 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $302.00 / $363.08
| Professional | | $288.40 | $302.00 | $363.08 |