- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.11 / $976.26 / $1,315.52
| Facility | | $346.11 | $976.26 | $1,315.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $346.11
| Professional | | $346.11 | $346.11 | $346.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.11 / $515.59 / $871.82
| Professional | | $346.11 | $515.59 | $871.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.52 / $326.52 / $346.11
| Facility | | $326.52 | $326.52 | $346.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.19 / $294.19 / $346.11
| Professional | | $294.19 | $294.19 | $346.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $346.11
| Facility | | $346.11 | $346.11 | $346.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.95 / $346.11 / $560.97
| Professional | | $314.95 | $346.11 | $560.97 |