- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.80 / $317.94 / $678.03
| Facility | | $306.80 | $317.94 | $678.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.80 / $311.77 / $371.23
| Professional | | $306.80 | $311.77 | $371.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.51 / $219.49 / $286.89
| Facility | | $158.51 | $219.49 | $286.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.89 / $286.89 / $292.64
| Professional | | $286.89 | $286.89 | $292.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.20 / $291.20 / $308.68
| Facility | | $291.20 | $291.20 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $308.68
| Professional | | $308.68 | $308.68 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.51 / $308.68 / $415.42
| Professional | | $302.51 | $308.68 | $415.42 |