- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.42 / $317.42 / $317.42
| Facility | | $317.42 | $317.42 | $317.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $350.38
| Professional | | $318.52 | $318.52 | $350.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.05 / $374.18 / $374.18
| Professional | | $318.05 | $374.18 | $374.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.50 / $300.50 / $300.50
| Facility | | $300.50 | $300.50 | $300.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $390.65 / $450.75
| Professional | | $318.52 | $390.65 | $450.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.00 / $318.52 / $318.52
| Professional | | $313.00 | $318.52 | $318.52 |