- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $305.02 / $311.13 / $320.27
| Facility | | $305.02 | $311.13 | $320.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.80 / $311.13 / $311.13
| Professional | | $303.80 | $311.13 | $311.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $334.53 / $334.53 / $334.53
| Facility | | $334.53 | $334.53 | $334.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.53 / $334.53 / $334.53
| Professional | | $334.53 | $334.53 | $334.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.98 / $311.13 / $311.13
| Facility | | $263.98 | $311.13 | $311.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.13 / $311.13 / $311.13
| Professional | | $311.13 | $311.13 | $311.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.02 / $305.02 / $347.72
| Professional | | $305.02 | $305.02 | $347.72 |