- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.80 / $306.80 / $306.80
| Facility | | $306.80 | $306.80 | $306.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $411.11
| Professional | | $308.68 | $308.68 | $411.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.80 / $306.80 / $308.68
| Professional | | $306.80 | $306.80 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $393.13
| Professional | | $308.68 | $308.68 | $393.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $325.51
| Professional | | $308.68 | $308.68 | $325.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.16 / $308.68 / $327.20
| Professional | | $290.16 | $308.68 | $327.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.92 / $293.92 / $293.92
| Professional | | $293.92 | $293.92 | $293.92 |