- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $321.72 / $384.08
| Professional | | $318.52 | $321.72 | $384.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $383.86 / $383.86 / $383.86
| Facility | | $383.86 | $383.86 | $383.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $383.86
| Professional | | $318.52 | $318.52 | $383.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.52 / $367.96 / $389.20
| Facility | | $318.52 | $367.96 | $389.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.81 / $383.86 / $405.68
| Professional | | $323.81 | $383.86 | $405.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $318.52
| Professional | | $318.52 | $318.52 | $318.52 |