- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $359.19 / $1,012.63 / $1,364.54
| Facility | | $359.19 | $1,012.63 | $1,364.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.19 / $359.19 / $359.19
| Professional | | $359.19 | $359.19 | $359.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.09 / $523.23 / $884.74
| Professional | | $359.09 | $523.23 | $884.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.86 / $338.86 / $359.19
| Facility | | $338.86 | $338.86 | $359.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.31 / $305.31 / $359.19
| Professional | | $305.31 | $305.31 | $359.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.86 / $359.19 / $582.16
| Professional | | $326.86 | $359.19 | $582.16 |