- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.18 / $346.62 / $368.88
| Professional | | $321.18 | $346.62 | $368.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $312.22 / $312.22 / $312.22
| Facility | | $312.22 | $312.22 | $312.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.73 / $312.22 / $318.00
| Professional | | $296.73 | $312.22 | $318.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $312.22 / $318.00 / $463.58
| Facility | | $312.22 | $318.00 | $463.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.22 / $345.00 / $450.00
| Professional | | $312.22 | $345.00 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.00 / $318.00 / $318.00
| Professional | | $318.00 | $318.00 | $318.00 |