- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $571.36
| Facility | | $318.52 | $318.52 | $571.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $384.08
| Professional | | $318.52 | $318.52 | $384.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $345.58 / $347.31 / $351.77
| Facility | | $345.58 | $347.31 | $351.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.77 / $347.31 / $351.77
| Professional | | $294.77 | $347.31 | $351.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $322.08 / $405.00
| Professional | | $318.52 | $322.08 | $405.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.42 / $349.05 / $573.35
| Facility | | $317.42 | $349.05 | $573.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.42 / $353.36 / $1,374.70
| Professional | | $317.42 | $353.36 | $1,374.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $385.10
| Professional | | $318.52 | $318.52 | $385.10 |