- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $357.33 / $407.72 / $408.38
| Facility | | $357.33 | $407.72 | $408.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.31 / $357.33 / $452.90
| Professional | | $340.31 | $357.33 | $452.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.00 / $325.04 / $325.04
| Facility | | $325.00 | $325.04 | $325.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.31 / $340.31 / $399.88
| Facility | | $340.31 | $340.31 | $399.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.91 / $340.31 / $340.31
| Professional | | $328.91 | $340.31 | $340.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.27 / $340.31 / $442.40
| Professional | | $306.27 | $340.31 | $442.40 |