- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $319.50 / $364.23 / $364.23
| Facility | | $319.50 | $364.23 | $364.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.23 / $364.23 / $364.23
| Professional | | $364.23 | $364.23 | $364.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.80 / $302.80 / $302.80
| Professional | | $302.80 | $302.80 | $302.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.10 / $238.10 / $238.10
| Professional | | $238.10 | $238.10 | $238.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.81 / $364.23 / $520.85
| Facility | | $327.81 | $364.23 | $520.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.00 / $327.00 / $327.00
| Professional | | $327.00 | $327.00 | $327.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.60 / $384.12 / $552.54
| Professional | | $293.60 | $384.12 | $552.54 |