- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.92 / $302.92 / $328.34
| Facility | | $302.92 | $302.92 | $328.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $394.01
| Professional | | $328.34 | $328.34 | $394.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.66 / $1,813.84 / $2,440.19
| Facility | | $1,494.66 | $1,813.84 | $2,440.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $328.34
| Professional | | $328.34 | $328.34 | $328.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $328.34
| Facility | | $328.34 | $328.34 | $328.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $373.71
| Professional | | $328.34 | $328.34 | $373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.08 / $328.34 / $365.51
| Professional | | $279.08 | $328.34 | $365.51 |