- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $356.93 / $1,087.69 / $1,324.76
| Facility | | $356.93 | $1,087.69 | $1,324.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.93 / $356.93 / $360.50
| Professional | | $356.93 | $356.93 | $360.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.61 / $348.61 / $356.93
| Professional | | $348.61 | $348.61 | $356.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.73 / $336.73 / $356.93
| Facility | | $336.73 | $336.73 | $356.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.93 / $356.93 / $438.05
| Professional | | $356.93 | $356.93 | $438.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.39 / $324.06 / $364.57
| Professional | | $303.39 | $324.06 | $364.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.93 / $397.34 / $525.41
| Professional | | $356.93 | $397.34 | $525.41 |