- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.52 / $990.35 / $1,206.20
| Facility | | $318.52 | $990.35 | $1,206.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $321.72
| Professional | | $318.52 | $318.52 | $321.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.42 / $317.42 / $371.32
| Professional | | $317.42 | $317.42 | $371.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.50 / $300.50 / $318.52
| Facility | | $300.50 | $300.50 | $318.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $405.00
| Professional | | $318.52 | $318.52 | $405.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.75 / $299.33 / $336.76
| Professional | | $270.75 | $299.33 | $336.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $350.56 / $375.87
| Professional | | $318.52 | $350.56 | $375.87 |