- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $343.16 / $352.12 / $352.12
| Facility | | $343.16 | $352.12 | $352.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.31 / $343.72 / $357.33
| Professional | | $340.31 | $343.72 | $357.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.31 / $385.26 / $510.47
| Facility | | $340.31 | $385.26 | $510.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.31 / $340.31 / $340.31
| Professional | | $340.31 | $340.31 | $340.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $321.05 / $328.91 / $340.31
| Facility | | $321.05 | $328.91 | $340.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.91 / $340.31 / $24,528.00
| Professional | | $328.91 | $340.31 | $24,528.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.12 / $340.31 / $401.90
| Professional | | $136.12 | $340.31 | $401.90 |